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PATH TO HEALTH DRUG FORMULARY
Administered by MedImpact
February 2019
INTRODUCTION
Foreword The below table describes Path to Health prescription coverage:
Patient out-of-pocket cost $5 copayment per prescription
No monthly share of cost requirement
Benefit maximums $500 per prescription claim
$1500 maximum benefit per Path to Health enrollment period
Drug exclusions Specialty drugs and contraceptives are excluded
This document represents the efforts of MedImpact and Path to Health to provide physicians and pharmacists with a method to evaluate the various drug products available under the Path to Health Benefit. The medical treatment of patients is frequently related to the practical application of drug therapy. Due to the vast availability of medication treatment modalities, a reasonable program of drug product selection and drug usage must be developed. The goal of the Path to Health Formulary is to enhance the ability of physicians and pharmacists participating in Path to Health to provide optimal cost effective drug therapy for Path to Health members. The development, maintenance, and improvement of the Path to Health Formulary are evolutionary and require on-going oversight. This is accomplished by a pharmacy and therapeutics review process conducted by a panel of physicians and pharmacists. The Path to Health Formulary is a continuously reviewed and revised list of drug products that reflects the consensus clinical opinion of the panel. Using this Formulary, you are encouraged to review the information and provide input and comments to Path to Health. Path to Health uses the following criteria in the evaluation of product selection for the Path to Health Formulary:
The drug product must demonstrate unequivocal safety for medical use. The drug product must be efficacious and be medically necessary for the treatment, maintenance or prophylaxis
of the medical condition. The drug product must demonstrate therapeutic marker outcomes accepted by the medical community. The drug product must be accepted for use by the medical community. The drug product should have a favorable cost ratio for the treatment of the medical condition.
How to Use the Drug Formulary The Path to Health Formulary is a list of covered and preferred drug agents for Path to Health members. All products are listed by their generic names and most common proprietary (branded) name. The Path to Health Formulary may be accessed by using the index, both by generic and proprietary name (in small capital letters) and by therapeutic drug category. Any product not found in this Formulary listing shall be considered a Non-Formulary Drug.
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Coverage Limitations The Path to Health Formulary does not provide information regarding the specific coverage or limitations an individual member may have. Path to Health members may have specific limitations which are not reflected in this Drug Formulary. This Drug Formulary contains only FDA-approved outpatient drugs for eligible members and does not apply to non-FDA approved drugs or medications used in in-patient settings. If a Path to Health member has any specific questions regarding coverage, they should contact Path to Health at (916) 649-2631 for further explanation of benefits. Path to Health members are not eligible to receive prescription drug services outside of California and the designated border state areas of Oregon, Nevada and Arizona.
Generic Substitution When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The brand names listed are for reference use only and do not denote coverage, unless specifically noted. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by the Path to Health pharmacy and therapeutics review process. Path to Health approves such multisource drugs for addition to the maximum allowable cost (MAC) list based on the following criteria:
A minimum of one “A” rated source of the product.
An FDA Rating for generic equivalency.
Review by Path to Health for efficacy and safety.
Certain drug products with complex pharmacokinetics, dosage forms, narrow therapeutic efficacy or where blood level maintenance is crucial will not be subject to substitution. These products are:
Coumadin
Dilantin
Lanoxin
Premarin
Synthroid This list is reviewed and updated periodically based on the clinical literature and available pharmacokinetic principals of the drug products. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.
Experimental Drugs The experimental nature or use of drug products will be determined by Path to Health using current medical literature. Any drug product or use of an existing product that is determined to be experimental will be excluded from coverage.
Prior Authorization Drug products that are listed as Prior Authorization (PA) required require approval when the member presents a prescription to a network pharmacy. To obtain coverage, the prescribing physician may:
A. Fax a completed Medication Request Form (MRF) to MedImpact at (858) 790-7100, or
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B. Contact MedImpact at (800) 788-2949 and provide all necessary information requested. If the request does not meet the criteria established by Path to Health, the request will be denied and alternative therapy may be recommended. Each request will be reviewed on individual patient need and approval may be given if a documented medical need exists.
Request Process for Non-Formulary Agents Coverage for non-formulary agents may be requested in advance by physicians. When a Path to Health member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist should notify the physician and member of the nonformulary status. The physician, pharmacist or member may then call MedImpact at (800) 788-2949 to initiate the medical exception process. To obtain coverage, the prescribing physician may:
A. Fax a completed Medication Request Form (MRF) to MedImpact at (858) 790-7100, or
B. Contact MedImpact at (800) 788-2949 and provide all necessary information requested.
The following general criteria are used for approval.
1) The use of Path to Health Formulary Drug Products is contraindicated in the patient. 2) The patient has failed an appropriate trial of Formulary or related agents. 3) The choices available in the Path to Health Formulary are not suited for the present patient care need and the
drug selected is required for patient safety. 4) The use of a Path to Health Formulary Drug may provoke an underlying condition, which would be detrimental to
patient care. Path to Health recognizes that not all medical needs can be met with agents listed in this document and encourages inquires about optional therapies.
Step Care Agents Drug products defined as step care will undergo an electronic pre-authorization process per Path to Health guidelines, which requires a trial of first-line drug(s) before a Step Care drug will be covered at the formulary brand level. If recommended guidelines for first-line therapy are not met, then the Step Care drug may be subject to review through the prior authorization process.
Quantity Limits Limitations on quantity may be placed on certain products due to safety, therapeutic or cost-effectiveness considerations. Prescriptions for such agents exceeding the quantity limit (QL) will be subject to the prior authorization process.
Appeals Process Prior authorization and medical exception requests are evaluated based on medical necessity and safety as described. In the event of denial, providers or Path to Health members may request a formal appeal verbally or in writing within sixty (60) days of denial notification. To request an appeal, call (800) 788-2949 or send your written appeal request to the following address:
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MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court, San Diego, CA 92131
Attention: Appeals Coordinator or
Fax (858) 790-6060
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Formulary Process and Communication The Path to Health Formulary is a tool to promote cost-effective prescription drug use. While every attempt has been made to create a document that meets all therapeutic needs, the art of medicine makes this a formidable task. Path to Health welcomes input on the formulary from physicians and pharmacists providing services to Path to Health clients. Suggestions and comments should be submitted to the Path to Health at the following address:
Path to Health ATTN: Pharmacy and Therapeutics Panel
1545 River Park Drive, Suite 435 Sacramento, CA 95815
(916) 649-2631
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TABLE OF CONTENTS
FOREWORD ................................................................................................................................................................................................. 1 HOW TO USE THE DRUG FORMULARY ........................................................................................................................................................ 1 COVERAGE LIMITATIONS ............................................................................................................................................................................ 2 GENERIC SUBSTITUTION ............................................................................................................................................................................. 2 EXPERIMENTAL DRUGS .............................................................................................................................................................................. 2 PRIOR AUTHORIZATION .............................................................................................................................................................................. 2 REQUEST PROCESS FOR NON-FORMULARY AGENTS ................................................................................................................................... 3 STEP CARE AGENTS .................................................................................................................................................................................... 3 QUANTITY LIMITS ...................................................................................................................................................................................... 3 APPEALS PROCESS ...................................................................................................................................................................................... 3 FORMULARY PROCESS AND COMMUNICATION ........................................................................................................................................... 5 CENTRAL NERVOUS SYSTEM AGENTS .......................................................................................................................... 10 ANALGESIC AND ANTI-INFLAMMATORY AGENTS ..................................................................................................................................... 10
Non-Steroidal Anti-Inflammatory Agents ............................................................................................................................................ 10 Miscellaneous Arthritis Agents ............................................................................................................................................................ 10 Migraine Agents ................................................................................................................................................................................... 10 Opiate Agonists .................................................................................................................................................................................... 10 Narcotic Withdrawal Therapy Agents .................................................................................................................................................. 11 Opiate Antagonists ............................................................................................................................................................................... 11 Miscellaneous Analgesics .................................................................................................................................................................... 11 Miscellaneous Central Nervous System Agents ................................................................................................................................... 11
ANTICONVULSANT AGENTS ...................................................................................................................................................................... 11 Barbiturate Anticonvulsants ................................................................................................................................................................ 11 Benzodiazepine Anticonvulsants .......................................................................................................................................................... 11 Hydantoin Anticonvulsants .................................................................................................................................................................. 11 Miscellaneous Anticonvulsants ............................................................................................................................................................ 11
ANTIPARKINSONIAN AGENTS ................................................................................................................................................................... 12 MUSCLE RELAXANT AGENTS ................................................................................................................................................................... 12
Skeletal Muscle Relaxants .................................................................................................................................................................... 12 PSYCHOTHERAPEUTIC AGENTS ................................................................................................................................................................. 12
Tricyclic Antidepressant Agents ........................................................................................................................................................... 12 S.S.R.I. Agents ...................................................................................................................................................................................... 12 S.N.R.I. Agents ..................................................................................................................................................................................... 12 M.A.O. Inhibitor Agents ....................................................................................................................................................................... 12 Miscellaneous Antidepressant Agents .................................................................................................................................................. 12 Antimanic Agents ................................................................................................................................................................................. 13 Benzodiazepines ................................................................................................................................................................................... 13 Antipsychotic Agents ............................................................................................................................................................................ 13 Antipsychotic/SSRI Combination Agents ............................................................................................................................................. 13 Miscellaneous Anxiolytics, Sedatives, and Hypnotics .......................................................................................................................... 13
CARDIOVASCULAR/BLOOD AGENTS .............................................................................................................................. 14 ANTIARRHYTHMIC AGENTS ...................................................................................................................................................................... 14
Antidysrhythmic Drug Agents .............................................................................................................................................................. 14 ANTIHYPERTENSIVE AGENTS .................................................................................................................................................................... 14
Alpha-Adrenergic Antagonist Antihypertensive Agents ....................................................................................................................... 14 Beta-Adrenergic Antagonist Agents ..................................................................................................................................................... 14 Combination Alpha-Beta Antagonist Agents........................................................................................................................................ 14 Angiotensin Converting Enzyme Inhibitor Agents ............................................................................................................................... 14 Angiotensin Receptor Blocker Agents .................................................................................................................................................. 14 Calcium Channel Blocking Agents....................................................................................................................................................... 15 Centrally Acting Antihypertensive Agents............................................................................................................................................ 15 Combination Antihypertensive Agents ................................................................................................................................................. 15 Drugs for Pheochromocytoma ............................................................................................................................................................. 15 Potassium-Sparing Diuretics ............................................................................................................................................................... 15 Loop Diuretics ..................................................................................................................................................................................... 15 Thiazide and Related Diuretics ............................................................................................................................................................ 15 Vasodilator Antihypertensive Agents ................................................................................................................................................... 15
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ANTILIPEMIC AGENTS .............................................................................................................................................................................. 16 BLOOD AGENTS ........................................................................................................................................................................................ 16
Coagulants and Anticoagulants ........................................................................................................................................................... 16 HEMORHEOLOGIC AGENTS ....................................................................................................................................................................... 16 CARDIAC GLYCOSIDE AGENTS ................................................................................................................................................................. 16 ANTIPLATELET AGENTS ........................................................................................................................................................................... 16 VASODILATING AGENTS ........................................................................................................................................................................... 16 GASTROINTESTINAL AGENTS .......................................................................................................................................... 16 ANTIDIARRHEAL AGENTS ......................................................................................................................................................................... 16 ANTIEMETIC AGENTS ............................................................................................................................................................................... 17 ANTIMUSCARINIC/ANTISPASMODIC AGENTS ............................................................................................................................................ 17 ANTIULCER/ANTIPEPTIC AGENTS ............................................................................................................................................................. 17 BOWEL EVACUANT AGENTS ..................................................................................................................................................................... 17 DIGESTIVE ENZYMES ................................................................................................................................................................................ 17 GALLSTONE SOLUBILIZING AGENTS ......................................................................................................................................................... 18 GASTROINTESTINAL STIMULANT AGENTS ................................................................................................................................................ 18 H2 ANTAGONIST AGENTS ......................................................................................................................................................................... 18 LAXATIVE AGENTS ................................................................................................................................................................................... 18 MISCELLANEOUS GASTROINTESTINAL SUPPLIES ...................................................................................................................................... 18 MISCELLANEOUS GASTROINTESTINAL AGENTS ........................................................................................................................................ 18 ANTI-INFECTIVE AGENTS .................................................................................................................................................. 18 AMEBICIDES ............................................................................................................................................................................................. 18 ANTIHELMINTIC AGENTS .......................................................................................................................................................................... 18 ANTIBIOTIC AGENTS ................................................................................................................................................................................. 18
Aminoglycosides .................................................................................................................................................................................. 18 Cephalosporins .................................................................................................................................................................................... 18 Macrolide Antibiotic Agents ................................................................................................................................................................ 19 Miscellaneous Antibiotic Agents .......................................................................................................................................................... 19 Penicillins ............................................................................................................................................................................................ 19 Quinolones ........................................................................................................................................................................................... 19 Sulfonamide Agents .............................................................................................................................................................................. 19 Tetracyclines ........................................................................................................................................................................................ 19
ANTIFUNGAL AGENTS .............................................................................................................................................................................. 19 ANTIMALARIAL AGENTS .......................................................................................................................................................................... 20 ANTITUBERCULOSIS AGENTS .................................................................................................................................................................... 20 ANTI-ULCER ERADICATION AGENTS ........................................................................................................................................................ 20 OTHER ANTIVIRAL AGENTS...................................................................................................................................................................... 20 LEPROSTATIC AGENTS .............................................................................................................................................................................. 20 RESPIRATORY/EENT AGENTS.......................................................................................................................................... 20 ANTIHISTAMINE AGENTS .......................................................................................................................................................................... 20
Single Entity Alkylamine Agents .......................................................................................................................................................... 20 Single Entity Ethanolamine Agents ...................................................................................................................................................... 20 Non-Sedating Single Entity Agents ...................................................................................................................................................... 20 Miscellaneous Antihistamine Agents.................................................................................................................................................... 21
ANTIHISTAMINE/DECONGESTANT COMBINATION AGENTS ....................................................................................................................... 21 Antihistamine/Decongestant Agents..................................................................................................................................................... 21
ANTITUSSIVE AGENTS .............................................................................................................................................................................. 21 Non-Narcotic Antitussive Agents ......................................................................................................................................................... 21 Narcotic Antitussive Agents ................................................................................................................................................................. 21 Decongestants ...................................................................................................................................................................................... 21
ASTHMA/COPD AGENTS .......................................................................................................................................................................... 21 Inhaled Sympathomimetic (Adrenergic) Agents ................................................................................................................................... 21 Oral Sympathomimetic (Adrenergic) Agents ....................................................................................................................................... 21 Inhaled Oral Corticosteroid Agents ..................................................................................................................................................... 22 Leukotriene Receptor Antagonists ....................................................................................................................................................... 22 Respiratory Smooth Muscle Relaxant Agents ...................................................................................................................................... 22
EXPECTORANT AGENTS ............................................................................................................................................................................ 22 MUCOLYTIC AGENTS ................................................................................................................................................................................ 22 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS ........................................................................................................................... 22
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Ophthalmic Antibiotic Agents .............................................................................................................................................................. 22 Ophthalmic Anti-Inflammatory Agents, Corticosteroid ....................................................................................................................... 22 Ophthalmic Anti-Inflammatory Agents, NSAIDs ................................................................................................................................. 22 Ophthalmic Antiviral Agents ................................................................................................................................................................ 22 Ophthalmic Beta Blockers ................................................................................................................................................................... 22 Ophthalmic Miotic Agents ................................................................................................................................................................... 23 Ophthalmic Mydriatic Agents .............................................................................................................................................................. 23 Ophthalmic Sulfonamide Agents .......................................................................................................................................................... 23 Miscellaneous Ophthalmic Agents ....................................................................................................................................................... 23 Otic Anti-Infective Agents .................................................................................................................................................................... 23 Miscellaneous Otic Agents ................................................................................................................................................................... 23
INHALED/ORAL EENT AGENTS ................................................................................................................................................................ 23 Inhaled Nasal Agents ........................................................................................................................................................................... 23 Carbonic Anhydrase Inhibitor Agents ................................................................................................................................................. 23 Local Anesthetic Agents ....................................................................................................................................................................... 23
MISCELLANEOUS EENT AGENTS ............................................................................................................................................................. 23 DIABETES AND THYROID AGENTS .................................................................................................................................. 24 ORAL DIABETES AGENTS ......................................................................................................................................................................... 24
Sulfonylureas ....................................................................................................................................................................................... 24 Non-Sulfonylureas................................................................................................................................................................................ 24 Combination Diabetes Agents .............................................................................................................................................................. 24
INSULIN AGENTS ...................................................................................................................................................................................... 24 MISCELLANEOUS DIABETES AGENTS ....................................................................................................................................................... 24 THYROID AGENTS ..................................................................................................................................................................................... 24
Antithyroid Agents ............................................................................................................................................................................... 25 HORMONE AGENTS ........................................................................................................................................................... 25 ORAL ADRENAL CORTICOSTEROID AGENTS ............................................................................................................................................. 25 ANDROGEN AGENTS ................................................................................................................................................................................. 25 BONE RESORPTION INHIBITORS ................................................................................................................................................................ 25 PARATHYROID HORMONE ......................................................................................................................................................................... 25 ESTROGEN AGENTS .................................................................................................................................................................................. 25
Estrogen Agonist-Antagonists .............................................................................................................................................................. 26 CONTRACEPTIVES ..................................................................................................................................................................................... 26 OXYTOCIC AGENTS .................................................................................................................................................................................. 26 PITUITARY AGENTS .................................................................................................................................................................................. 26 PROGESTIN AGENTS ................................................................................................................................................................................. 26 GENITOURINARY AGENTS ................................................................................................................................................ 26 URINARY ANTI-INFECTIVE AGENTS ......................................................................................................................................................... 26 URINARY ANTI-SPASMODIC AGENTS ....................................................................................................................................................... 26 GENITOURINARY SMOOTH MUSCLE RELAXANT AGENTS ......................................................................................................................... 26 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS .................................................................................................................................. 26 TOPICAL/MUCOUS MEMBRANE AGENTS ....................................................................................................................... 27 KERATOLYTIC AGENTS ............................................................................................................................................................................. 27 MISCELLANEOUS SKIN/MUCOUS MEMBRANE AGENTS ............................................................................................................................ 27 TOPICAL ANTIBIOTIC AGENTS .................................................................................................................................................................. 27 TOPICAL ANTIFUNGAL AGENTS ................................................................................................................................................................ 27 VAGINAL ANTIFUNGAL AGENTS .............................................................................................................................................................. 27 VAGINAL ANTI-INFECTIVE AGENTS ......................................................................................................................................................... 28 TOPICAL ANTI-INFLAMMATORY AGENTS ................................................................................................................................................. 28 TOPICAL ANTIPRURITIC AND LOCAL ANESTHETIC AGENTS ...................................................................................................................... 28 TOPICAL ANTIVIRAL AGENTS ................................................................................................................................................................... 28 TOPICAL MISCELLANEOUS ANTI-INFECTIVE AGENTS ............................................................................................................................... 28 SCABICIDE/PEDICULICIDE AGENTS ........................................................................................................................................................... 29 MISCELLANEOUS/UNCLASSIFIED AGENTS ................................................................................................................... 29 ELECTROLYTE AGENTS ............................................................................................................................................................................ 29
Miscellaneous Agents ........................................................................................................................................................................... 29 Potassium Agents ................................................................................................................................................................................. 29
HEAVY METAL ANTAGONIST AGENTS ..................................................................................................................................................... 30 VITAMIN AGENTS ..................................................................................................................................................................................... 30
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Vitamin B-Complex Agents .................................................................................................................................................................. 30 Vitamin D ............................................................................................................................................................................................. 30 Vitamin K Activity Agents .................................................................................................................................................................... 30 Iron Agents ........................................................................................................................................................................................... 30
DIAGNOSTIC TESTING ............................................................................................................................................................................... 30 Blood Glucose Supplies ....................................................................................................................................................................... 30
ALCOHOL AND SMOKING DETERRENT AGENTS ....................................................................................................................................... 30 GOUT AGENTS .......................................................................................................................................................................................... 30 OTHER MEDICAL SUPPLIES ....................................................................................................................................................................... 31
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CENTRAL NERVOUS SYSTEM AGENTS
Analgesic and Anti-Inflammatory Agents Non-Steroidal Anti-Inflammatory Agents FIRST LINE AGENTS Aspirin ASPIRIN Aspirin EC ECOTRIN Celecoxib CELEBREX Diclofenac Sodium VOLTAREN Etodolac LODINE Ibuprofen MOTRIN (INCLUDES OTC) Indomethacin INDOCIN Ketoprofen ORUVAIL, 200MG STRENGTH NON-FORMULARY Indomethacin, Sustained Release INDOCIN SR Meloxicam Tablets MOBIC (TABLETS ONLY), SUSPENSION NON-FORMULARY Nabumetone
RELAFEN
Naproxen NAPROSYN Naproxen Sodium ANAPROX
ANAPROX DS Salsalate DISALCID Sulindac CLINORIL Piroxicam FELDENE SECOND LINE AGENTS SE Etodolac Extended Release LODINE XL, STEP THERAPY, RESTRICTED TO A TRIAL OF 2
UNRESTRICTED NSAIDS IN THE PAST 90 DAYS Miscellaneous Arthritis Agents Leflunomide ARAVA Migraine Agents APAP/Dichloralphenazone/Isomethep MIDRIN Butalbital/APAP/Caffeine ESGIC ESGIC PLUS FIORICET Butalbital/Aspirin/Caffeine (Tablets Only) FIORINAL Ergotamine/Caffeine CAFERGOT QL Naratriptan AMERGE, LIMITED TO 9 TABLETS/MONTH, ONLY 1 RX FOR ANY
TRIPTAN/MONTH QL Rizatriptan MAXALT, MAXALT MLT, LIMITED TO 9 TABLETS/MONTH, ONLY 1
RX FOR ANY TRIPTAN/MONTH QL Sumatriptan IMITREX, LIMITED TO 4 INJECTIONS, 9 TABLETS, OR 6 NASAL
UNITS PER MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH, SUMAVEL NON-FORMULARY
SE, QL Eletriptan RELPAX, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF SUMATRIPTAN IN THE PAST 120 DAYS, LIMITED TO 9
TABLETS/MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH SE, QL Zolmitriptan ZOMIG, ZOMIG ZMT STEP THERAPY, RESTRICTED TO USE
AFTER A TRIAL OF SUMATRIPTAN IN THE PAST 120 DAYS, LIMITED TO 9 TABLETS OR 6 NASAL UNITS PER MONTH, ONLY
1 RX FOR ANY TRIPTAN/MONTH PA, QL Dihydroergotamine MIGRANAL, PA REQ, LIMITED TO 1 KIT (4 TREATMENTS) PER
MONTH Opiate Agonists
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QL Acetaminophen/Codeine TYLENOL #2, #3, #4, LIMITED TO #240/MONTH OR
960ML/MONTH ; ORAL SUSPENSION AND VOPAC NON-FORMULARY
QL Acetaminophen/Hydrocodone NORCO 5/325, LIMITED TO #240/MONTH QL NORCO 7.5/325, LIMITED TO #180/MONTH QL NORCO 10/325, LIMITED TO #150/MONTH ALL OTHER HYDROCODONE/APAP STRENGTHS NON-FORMULARY QL Butalbital/APAP/Caffeine/Codeine FIORICET/CODEINE, LIMITED TO #180/MONTH QL Butalbital/Aspirin/Caffeine/Codeine FIORINAL/CODEINE, LIMITED TO #180/MONTH QL Codeine/Aspirin EMPIRIN #2, #3, #4, LIMITED TO #240/MONTH QL Hydromorphone DILAUDID, LIMITED TO #240/MONTH OR 960ML/MONTH QL Morphine MSIR, LIMITED TO #240/MONTH OR 960ML/MONTH QL Morphine SR MS CONTIN/ORAMORPH SR, LIMITED TO #120/MONTH QL Oxycodone OXYIR, LIMITED TO #240/MONTH QL Oxycodone OXYFAST, LIMITED TO #960ML/MONTH QL Oxycodone/Acetaminophen PERCOCET, LIMITED TO #240/MONTH; MAGNACET AND
PRIMALEV NON-FORMULARY QL TYLOX, LIMITED TO #240/MONTH QL Oxycodone/Aspirin PERCODAN, LIMITED TO #240/MONTH PA, QL Oxycodone OXYCONTIN, PA REQ, LIMITED TO #60/MONTH Narcotic Withdrawal Therapy Agents Naloxone Spray and Syringes NARCAN; EVZIO NON-FORMULARY Opiate Antagonists Naltrexone REVIA Miscellaneous Analgesics Acetaminophen TYLENOL Tramadol ULTRAM ; ULTRAM ER NON-FORMULARY PA, QL Butorphanol NS STADOL NS, PA REQ, LIMITED TO 2 BOTTLES/MONTH Miscellaneous Central Nervous System Agents Donepezil ARICEPT
Anticonvulsant Agents
Barbiturate Anticonvulsants Mephobarbital MEBARAL Phenobarbital PHENOBARBITAL Primidone MYSOLINE Benzodiazepine Anticonvulsants QL Clonazepam KLONOPIN, LIMITED TO #90/MONTH; RAPDIS TABLETS NON-
FORMULARY Hydantoin Anticonvulsants Phenytoin DILANTIN, PHENYTEK Miscellaneous Anticonvulsants Carbamazepine TEGRETOL; EQUETRO NON-FORMULARY Carbamazepine Extended Release TEGRETOL XR Divalproex Sodium DEPAKOTE Divalproex Sodium Extended Release DEPAKOTE ER Gabapentin NEURONTIN Levetiracetam KEPPRA Oxcarbazepine TRILEPTAL Tiagabine GABITRIL Valproic Acid DEPAKENE Zonisamide ZONEGRAN QL Lamotrigine LAMICTAL, LIMITED TO #60/MONTH FOR 100MG AND 150MG,
#180/MONTH FOR 25MG
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QL Topiramate TOPAMAX, LIMITED TO #90/MONTH FOR 25MG, 50MG AND
100MG STRENGTHS
Antiparkinsonian Agents Amantadine SYMMETREL Benztropine Mesylate COGENTIN Bromocriptine PARLODEL Carbidopa/Levodopa SINEMET; PARCOPA NON-FORMULARY Carbidopa/Levodopa CR SINEMET CR Pramipexole MIRAPEX Ropinirole REQUIP; REQUIP XL NON-FORMULARY Selegiline SELEGILINE, ZELAPAR AND EMSAM NON-FORMULARY Trihexyphenidyl ARTANE
Muscle Relaxant Agents Skeletal Muscle Relaxants Baclofen LIORESAL QL Carisoprodol SOMA, LIMITED TO #120/MONTH; 250 STRENGTH NON-
FORMULARY Chlorzoxazone PARAFON DSC Cyclobenzaprine FLEXERIL Dantrolene Sodium DANTRIUM Methocarbamol ROBAXIN Orphenadrine Citrate NORFLEX Orphenadrine/Aspirin/Caffeine NORGESIC
Psychotherapeutic Agents Tricyclic Antidepressant Agents Amitriptyline ELAVIL Amoxapine ASENDIN Desipramine NORPRAMIN Doxepin SINEQUAN Imipramine TOFRANIL, TOFRANIL PM NON-FORMULARY Maprotiline LUDIOMIL Nortriptyline PAMELOR Protriptyline VIVACTIL
S.S.R.I. Agents Citalopram CELEXA Fluoxetine Capsules PROZAC CAPSULES (10MG, 20MG ONLY), TABLETS NON-
FORMULARY Fluvoxamine LUVOX Paroxetine PAXIL Sertraline ZOLOFT
S.N.R.I. Agents QL Duloxetine CYMBALTA , LIMITED TO #60/MONTH QL Venlafaxine EFFEXOR, LIMITED TO #60/MONTH IF DOSE ≤ 200MG/DAY,
LIMITED TO #90/MONTH OF DOSE > 200MG/DAY QL Venlafaxine Extended Release EFFEXOR XR, LIMITED TO #30/MONTH VENLAFAXINE
EXTENDED RELEASE TABLETS NON-FORMULARY
M.A.O. Inhibitor Agents Phenelzine NARDIL Tranylcypromine PARNATE
Miscellaneous Antidepressant Agents
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Bupropion WELLBUTRIN, APLENZIN NON-FORMULARY Bupropion SR WELLBUTRIN SR, APLENZIN NON-FORMULARY Bupropion XL WELLBUTRIN XL, APLENZIN NON-FORMULARY Clomipramine ANAFRANIL Mirtazapine REMERON TAB, SOLTABS AND 7.5MG TABLETS NON-
FORMULARY Trazodone DESYREL MD, QL Nefazodone SERZONE, RESTRICTED TO PSYCHIATRY, LIMITED TO
#60/MONTH Antimanic Agents Lithium Carbonate ESKALITH LITHOBID Benzodiazepines QL Alprazolam XANAX, LIMITED TO #90/MONTH; XANAX XR, NIRAVAM, AND
ALPRAZOLAM INTENSOL NON-FORMULARY QL Clorazepate TRANXENE, LIMITED TO #90/MONTH QL Chlordiazepoxide LIBRIUM, LIMITED TO #90/MONTH QL Diazepam VALIUM, LIMITED TO #90/MONTH, DIASTAT NON-FORMULARY QL Flurazepam DALMANE, LIMITED TO #30/MONTH QL Lorazepam ATIVAN, LIMITED TO #90/MONTH; LORAZEPAM ORAL
CONCENTRATE NON-FORMULARY QL Temazepam RESTORIL, LIMITED TO #30/MONTH; 22.5MG STRENGTH NON-
FORMULARY QL Triazolam HALCION, LIMITED TO #30/MONTH Antipsychotic Agents QL Asenapine SAPHRIS, LIMITED TO #60 PER MONTH QL Aripiprazole ABILIFY, LIMITED TO #30 PER MONTH DISCMELTS NON-
FORMULARY Chlorpromazine THORAZINE Clozapine CLOZARIL Fluphenazine PROLIXIN Haloperidol HALDOL, HALDOL DECANOATE-VIALS ONLY Loxapine LOXITANE Molindone MOBAN QL Olanzapine ZYPREXA, LIMITED TO #60/MONTH QL ZYPREXA ZYDIS, LIMITED TO #60/MONTH ZYPREXA INJECTION ZYPREXA RELPREVV Perphenazine TRILAFON Pimozide ORAP QL Quetiapine SEROQUEL, LIMITED TO #90/MONTH, 25MG STRENGTH NON-
FORMULARY. 25MG STRENGTH NOT COVERED FOR
INSOMNIA, SUBMIT PA FOR OTHER INDICATIONS. QL Risperidone RISPERDAL, LIMITED TO #60/MONTH Thioridazine MELLARIL Thiothixene NAVANE Trifluoperazine STELAZINE QL Ziprasidone GEODON, LIMITED TO #60/MONTH Antipsychotic/SSRI Combination Agents QL Olanzapine/Fluoxetine HCl SYMBYAX, LIMITED TO #30/MONTH Miscellaneous Anxiolytics, Sedatives, and Hypnotics Buspirone BUSPAR
7.5MG STRENGTH NON-FORMULARY Chloral Hydrate NOCTEC Hydroxyzine ATARAX
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Hydroxyzine Pamoate VISTARIL Promethazine PHENERGAN QL Zolpidem AMBIEN, LIMITED TO #14/MONTH, AMBIEN CR AND EDLUAR
NON-FORMULARY
CARDIOVASCULAR/BLOOD AGENTS Antiarrhythmic Agents Antidysrhythmic Drug Agents Amiodarone CORDARONE; 100MG STRENGTH NON-FORMULARY Disopyramide NORPACE Disopyramide CR NORPACE CR Flecainide TAMBOCOR Mexiletine MEXITIL Procainamide PRONESTYL Procainamide SR PROCAN SR PROCANBID Propafenone RYTHMOL Quinidine Gluconate QUINAGLUTE Quinidine Polygalacturonate CARDIOQUIN Quinidine Sulfate CIN-QUIN Quinidine Sulfate SR QUINIDEX Sotalol BETAPACE
Antihypertensive Agents Alpha-Adrenergic Antagonist Antihypertensive Agents Reserpine SERPASIL Beta-Adrenergic Antagonist Agents Atenolol TENORMIN Metoprolol Succinate TOPROL XL Metoprolol Tartrate LOPRESSOR Nadolol CORGARD Pindolol VISKEN Propranolol INDERAL Propranolol LA INDERAL LA Combination Alpha-Beta Antagonist Agents Carvedilol COREG; COREG CR NON-FORMULARY Labetalol NORMODYNE TRANDATE Angiotensin Converting Enzyme Inhibitor Agents Benazepril LOTENSIN Captopril CAPOTEN Enalapril VASOTEC Lisinopril PRINIVIL ZESTRIL Angiotensin Receptor Blocker Agents Irbesartan AVAPRO Losartan COZAAR Telmisartan MICARDIS SE, QL Olmesartan BENICAR, STEP THERAPY, LIMITED TO #30/MONTH,
RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR
LOSARTAN/HCTZ IN THE PAST 90 DAYS SE, QL Valsartan DIOVAN, STEP THERAPY, LIMITED TO #60/MONTH,
RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR
LOSARTAN/HCTZ IN THE PAST 90 DAYS
15
Calcium Channel Blocking Agents Amlodipine NORVASC, LIMITED TO #30/MONTH Diltiazem CARDIZEM Diltiazem SR CARDIZEM SR; CARDIZEM LA NON-FORMULARY Diltiazem CD CARTIA XT Felodipine PLENDIL, LIMITED TO #30/MONTH Nifedipine, Sustained Release ADALAT CC Verapamil CALAN Verapamil LA Tablets CALAN SR; COVERA-HS NON-FORMULARY Verapamil SR Capsules VERELAN Centrally Acting Antihypertensive Agents Clonidine CATAPRES Guanfacine TENEX Methyldopa ALDOMET Combination Antihypertensive Agents Atenolol/Chlorthalidone TENORETIC Benazepril/HCTZ LOTENSIN HCT Bisoprolol/HCTZ ZIAC Captopril/HCTZ CAPOZIDE Enalapril/HCTZ VASORETIC Lisinopril/HCTZ ZESTORETIC
PRINZIDE Losartan/HCTZ HYZAAR, SE, QL Olmesartan/HCTZ BENICAR HCT, STEP THERAPY, LIMITED TO #30/MONTH,
RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR
LOSARTAN/HCTZ IN THE PAST 90 DAYS SE, QL Valsartan/HCTZ DIOVAN HCT, STEP THERAPY, LIMITED TO #30/MONTH,
RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR
LOSARTAN/HCTZ IN THE PAST 90 DAYS Drugs for Pheochromocytoma PA Phenoxybenzamine DIBENZYLINE, PA REQUIRED Potassium-Sparing Diuretics Spironolactone ALDACTONE Spironolactone/HCTZ ALDACTAZIDE Triamterene DYRENIUM Triamterene 37.5mg/HCTZ 25mg DYAZIDE Triamterene 37.5mg/HCTZ 25mg DYAZIDE Triamterene 75mg/HCTZ 50mg MAXZIDE 50 Loop Diuretics Bumetanide BUMEX Furosemide LASIX Thiazide and Related Diuretics Chlorthalidone HYGROTON Hydrochlorothiazide (HCTZ) HYDRODIURIL Indapamide LOZOL Metolazone ZAROXOLYN Vasodilator Antihypertensive Agents Doxazosin Mesylate CARDURA; CARDURAL XL NON-FORMULARY Hydralazine APRESOLINE Minoxidil LONITEN Prazosin MINIPRESS Terazosin HYTRIN
16
Antilipemic Agents Atorvastatin LIPITOR Cholestyramine/Aspartame QUESTRAN LIGHT Cholestyramine/Sucrose QUESTRAN Gemfibrozil LOPID Lovastatin MEVACOR Niacin NIACIN Pravastatin PRAVACHOL Niacin, Delayed Release NIASPAN Niacin/Lovastatin ADVICOR Simvastatin ZOCOR, 80MG STRENGTH RESTRICTED TO PRIOR USE OF
80MG DUE TO MYOPATHY RISK; ALL OTHER STRENGTHS
FORMULARY
Blood Agents Coagulants and Anticoagulants QL Enoxaparin LOVENOX, LIMITED TO #20/FILL TIMES 3 Warfarin Sodium COUMADIN
Hemorheologic Agents Pentoxifylline TRENTAL
Cardiac Glycoside Agents Digoxin LANOXIN; LANOXICAPS NON-FORMULARY
Antiplatelet Agents Cilostazole PLETAL Clopidogrel PLAVIX Dipyridamole PERSANTINE Pasugrel EFFIENT
Vasodilating Agents Isosorbide Dinitrate ISORDIL; CHEW TABLETS NON-FORMULARY Isosorbide Dinitrate SR DILATRATE SR Isosorbide Mononitrate ISOSORBIDE MONONITRATE Isosorbide Dinitrate ER ISOSORBIDE MONONITRATE Nitroglycerin Ointment NITROL Nitroglycerin Patches NITRO-DUR Nitroglycerin Spray NITROLINGUAL SPRAY Nitroglycerin Sublingual NITROSTAT SL SE Isosorbide Mononitrate IMDUR, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF ISOSORBIDE DINITRATE OR ISOSORBIDE DINITRATE SR IN
THE PAST 90 DAYS
GASTROINTESTINAL AGENTS
Antidiarrheal Agents Attapulgite PAREPECTOLIN Bismuth Subsalicylate PEPTO BISMOL
17
Diphenoxylate/Atropine LOMOTIL Kaolin/Pectin KAOPECTATE Loperamide IMODIUM
Antiemetic Agents Meclizine ANTIVERT Metoclopramide REGLAN Ondansetron ODT Tablets ZOFRAN ODT Ondansetron Tablets ZOFRAN TABLETS Ondansetron Solution ZOFRAN SOLUTION Prochlorperazine Maleate COMPAZINE
COMPAZINE SPANSULES NOT COVERED
Promethazine PHENERGAN Trimethobenzamide TIGAN
Antimuscarinic/Antispasmodic Agents Belladonna/Phenobarbital
(Extentabs, Capsules Not Covered) DONNATAL
Chlordiazepoxide/Clidinium CHLORDIAZEPOXIDE/CLIDINIUM Dicyclomine BENTYL Hyoscyamine Sulfate LEVBID LEVSIN LEVSIN SL
Antiulcer/Antipeptic Agents Antacid Mg OH/Al OH MAALOX, TC Antacid Mg OH/Al OH/Simethicone MYLANTA I, II Lansoprazole 15mg OTC PREVACID 24HR,
LEGEND LANSOPRAZOLE NON-FORMULARY Misoprostol CYTOTEC Omeprazole 20mg and 40mg PRILOSEC 20MG AND 40MG, OTHER STRENGTHS NON-
FORMULARY Omeprazole Magnesium PRILOSEC OTC Pantoprazole Tablets PROTONIX Simethicone MYLICON Sucralfate CARAFATE
Bowel Evacuant Agents QL Bowel Evacuation Prep Kits FLEET PREP KIT 1, LIMITED TO #2 KITS/MONTH AND 4 FILLS
PER YEAR FLEET PREP KIT 2, LIMITED TO #2 KITS/MONTH AND 4 FILLS
PER YEAR FLEET PREP KIT 3, LIMITED TO #2 KITS/MONTH AND 4 FILLS
PER YEAR QL Enema FLEET ENEMA, LIMITED TO #2 ENEMAS/MONTH AND 4 FILLS
PER YEAR Oral Colon Lavage Solution COLYTE QL Oral Saline Laxative FLEET PHOSPHO-SODA, LIMITED TO #2 BOTTLES/MONTH AND
4 FILLS PER YEAR
Digestive Enzymes Amylase/Lipase/Protease PANCRELIPASE 5,000 Amylase/Lipase/Protease CREON
18
Amylase/Lipase/Protease PANCREAZE
Gallstone Solubilizing Agents Ursodiol ACTIGALL
Gastrointestinal Stimulant Agents Metoclopramide REGLAN
H2 Antagonist Agents Cimetidine TAGAMET Famotidine PEPCID Ranitidine ZANTAC (TABLETS ONLY)
Laxative Agents QL Bisacodyl Suppositories DULCOLAX, LIMITED TO #30/MONTH Docusate Sodium Capsules COLACE QL Lactulose CEPHULAC, LIMITED TO 4L/MONTH QL CHRONULAC, LIMITED TO 4L/MONTH Sennosides SENNA
Miscellaneous Gastrointestinal Supplies Ostomy Supplies
Miscellaneous Gastrointestinal Agents Mesalamine DELZICOL ROWASA Olsalazine DIPENTUM Sulfasalazine AZULFIDINE PA Budesonide ENTOCORT EC, PA REQ
ANTI-INFECTIVE AGENTS
Amebicides Metronidazole FLAGYL; FLAGYL ER NON-FORMULARY Iodoquinol (Diiodohydroxyquin) YODOXIN
Antihelmintic Agents Albendazole ALBENZA Furazolidone FUROXONE Mebendazole VERMOX Praziquantel BILTRICIDE
Antibiotic Agents Aminoglycosides Neomycin Sulfate MYCIFRADIN Cephalosporins Cefaclor CECLOR
19
Cefadroxil DURICEF Cefdinir OMNICEF QL Cefixime SUPRAX, LIMITED TO #1 X 400MG/FILL Cefuroxime Tablets CEFTIN Cephalexin KEFLEX; 750MG STRENGTH NON-FORMULARY Macrolide Antibiotic Agents QL Azithromycin ZITHROMAX, LIMITED TO A 5-DAY SUPPLY; ZMAX NON-
FORMULARY Erythromycin Base ERY-TAB PCE ERYPED SUSPENSION Erythromycin Stearate ERYTHROCIN Erythromycin Ethylsuccinate EES Erythromycin/Sulfisoxazole PEDIAZOLE PA Clarithromycin BIAXIN, PA REQ Miscellaneous Antibiotic Agents Clindamycin CLEOCIN Metronidazole FLAGYL Penicillins Amoxicillin AMOXIL TRIMOX Amoxicillin/Potassium Clavulanate AUGMENTIN Ampicillin PRINCIPEN Dicloxacillin DYNAPEN Penicillin VK (125mg Tablets Not
Covered) PEN VK
Quinolones QL Ciprofloxacin tablets CIPRO TABLETS ONLY, LIMITED TO 21-DAY SUPPLY; CIPRO XR
AND PROQUIN XR NONFORMULARY QL Moxifloxacin AVELOX, LIMITED TO 21-DAY SUPPLY Sulfonamide Agents Erythromycin/Sulfisoxazole PEDIAZOLE Sulfamethoxazole/Trimethoprim
(SMZ/TMP) BACTRIM SEPTRA
Sulfisoxazole GANTRISIN Sulfadiazine SULFADIAZINE Trimethoprim TRIMPEX Tetracyclines Doxycycline VIBRAMYCIN VIBRA-TABS
DORYX, PERIOSTAT, AND ORACEA NON-FORMULARY Minocycline MINOCIN Tetracycline ACHROMYCIN V SUMYCIN
Antifungal Agents Clotrimazole MYCELEX TROCHE Fluconazole DIFLUCAN Griseofulvin Ultramicrosized GRIS-PEG FULVICIN P/G Ketoconazole NIZORAL Nystatin (Oral Powder Not Covered) MYCOSTATIN Terbinafine Tablets LAMISIL TABLETS
20
Antimalarial Agents Atovaquone/Proguanil MALARONE Chloroquine Phosphate CHLOROQUINE PHOSPHATE Hydroxychloroquine PLAQUENIL Iodoquinol YODOXIN Mefloquine LARIAM Primaquine PRIMAQUINE Pyrimethamine DARAPRIM Quinine (260mg Not Covered) QUININE
Antituberculosis Agents Ethambutol MYAMBUTOL Isoniazid ISONIAZID Pyrazinamide PYRAZINAMIDE Rifabutin MYCOBUTIN Rifampin RIFADIN
Anti-Ulcer Eradication Agents QL Amoxicillin/Clarithromycin/Lansoprazole PREVPAC, LIMITED TO 14-DAY SUPPLY/YEAR QL Tetracycline/Bismuth/Metronidazole HELIDAC, LIMITED TO 14-DAY SUPPLY/YEAR
Other Antiviral Agents Amantadine SYMMETREL Acyclovir Oral ZOVIRAX ORAL Oseltamivir TAMIFLU, QTY LIMITED TO A 5-DAY COURSE OF TREATMENT
OF EITHER TAMIFLU OR RELENZA PER 6 MONTHS Rimantadine FLUMADINE Zanamivir RELENZA, QTY LIMITED TO A 5-DAY COURSE OF TREATMENT
OF EITHER RELENZA OR TAMIFLU PER 6 MONTHS Valacyclovir VALTREX SE Famciclovir FAMVIR, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF ACYCLOVIR IN THE PAST 90 DAYS
Leprostatic Agents
Clofazimine LAMPRENE Dapsone DAPSONE; ACZONE NON-FORMULARY
RESPIRATORY/EENT AGENTS
Antihistamine Agents Single Entity Alkylamine Agents Chlorpheniramine CHLORTRIMETON Dexchlorpheniramine POLARAMINE Single Entity Ethanolamine Agents
Cyproheptadine PERIACTIN Diphenhydramine BENADRYL Non-Sedating Single Entity Agents
Cetirizine, OTC CETIRIZINE, OTC Fexofenadine FEXOFENADINE Loratadine, OTC LORATADINE, OTC
21
Miscellaneous Antihistamine Agents
Hydroxyzine ATARAX Hydroxyzine Pamoate VISTARIL Promethazine PHENERGAN
Antihistamine/Decongestant Combination Agents
Antihistamine/Decongestant Agents
Bromphen/Pseudoephedrine BROMFED BROMFED PD
Guaifenesin/Pseudoephedrine GUAIFED-PD Pseudoephedrine/Chlorpheniramine DECONAMINE SR
Antitussive Agents
Non-Narcotic Antitussive Agents
Benzonatate TESSALON Dextromethorphan TUSSIN PEDIATRIC Promethazine/Dextromethorphan PHENERGAN W/DEXTROMETHORPHAN Narcotic Antitussive Agents Codeine/Chlorpheniramine/
Pseudoephedrine NOVAHISTINE DH
Guaifenesin/Codeine ROBITUSSIN A-C Guaifenesin/Codeine/Pseudoephedrine NOVAHISTINE EXPECTORANT ROBITUSSIN DAC Phenylephrine/Hydrocodone/
Chlorpheniramine HISTUSSIN HC ENDAL-HD
Promethazine/Codeine PHENERGAN/CODEINE Promethazine/Phenylephrine/Codeine PHENERGAN VC/CODEINE Terpin Hydrate/Codeine TERPIN HYDRATE/CODEINE Triprolidine/Pseudoephedrine/Codeine ACTIFED/CODEINE Decongestants Pseudoephedrine SUDAFED
Asthma/COPD Agents
Inhaled Sympathomimetic (Adrenergic) Agents
QL Albuterol HFA PROVENTIL HFA , LIMITED TO #2 INHALERS/MONTH, PROAIR
HFA, VENTOLIN HFA, AND XOPENEX HFA NON-FORMULARY. QL Albuterol/Ipratropium COMBIVENT RESPIMAT, LIMITED TO #1 INHALER/MONTH QL Formoterol FORADIL, LIMITED TO #60/MONTH Ipratropium ATROVENT HFA QL Pirbuterol Acetate MAXAIR, LIMITED TO #2 INHALERS/MONTH
MAXAIR AUTOHALER, LIMITED TO #2 INHALERS/MONTH QL Salmeterol SEREVENT, LIMITED TO #1 INHALER/MONTH OR #60
BLISTERS/MONTH SE, QL
Mometasone/Formoterol DULERA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF ORAL INHALED STEROID (IF ASTHMA), ANTICHOLINERGIC, OR ANTICHOLINERGIC/LABA IN THE PAST 90 DAYS, LIMITED TO
#1 INHALER/MONTH SE, QL
Salmeterol/Fluticasone ADVAIR DISKUS 250/50 STRENGTH ONLY, STEP THERAPY, RESTRICTED TO COPD AFTER A TRIAL ANTICHOLINERGIC OR
LABA IN THE PAST 90 DAYS, LIMITED TO #1 INHALER/MONTH Oral Sympathomimetic (Adrenergic) Agents
Albuterol PROVENTIL Albuterol E.R. PROVENTIL REPETABS VOLMAX
22
Metaproterenol Oral ALUPENT Terbutaline Sulfate BRETHINE BRICANYL Inhaled Oral Corticosteroid Agents QL Beclomethasone Inhaler QVAR REDIHALER, LIMITED TO #2 INHALERS/MONTH QL Mometasone Inhaler ASMANEX, LIMITED TO #2 INHALERS/MONTH Leukotriene Receptor Antagonists QL Montelukast SINGULAIR, LIMITED TO #30/MONTH Respiratory Smooth Muscle Relaxant Agents Aminophylline 150mg/5ml Aminophylline Suppositories Theophylline, 80mg/15cc (Alcohol Free) SLO-PHYLLIN 80 Theophylline SLO-PHYLLIN Theophylline, Sustained Release THEO-DUR, SLO-BID, UNIPHYL
Expectorant Agents Guaifenesin ROBITUSSIN Guaifenesin/Dextromethorphan ROBITUSSIN DM Guaifenesin/Phenylephrine ENDAL Guaifenesin/Pseudoephedrine ZEPHREX LA Phenylephrine/Promethazine PHENERGAN VC Phenylephrine/Guaifenesin RESCON GC Potassium Iodide SSKI
Mucolytic Agents
Acetylcysteine MUCOMYST
Eye, Ear, Nose and Throat (EENT) Preparations
Ophthalmic Antibiotic Agents
Bacitracin BACITRACIN Dexamethasone/Polymyxin/Neomycin MAXITROL Erythromycin Base ILOTYCIN Gentamicin GARAMYCIN Gentamicin/Prednisolone PRED-G Hydrocortisone/Neomycin/Polymyxin CORTISPORIN OPHTHALMIC Neomycin/Gramicidin/Polymyxin NEOSPORIN OPHTHALMIC Ofloxacin OCUFLOX Polymixin B Sulfate/TMP POLYTRIM Tobramycin TOBREX Ophthalmic Anti-Inflammatory Agents, Corticosteroid
Fluorometholone EFLONE FML FML FORTE Prednisolone Acetate PRED MILD OPHTHALMIC PRED FORTE Prednisolone Phosphate INFLAMASE INFLAMASE FORTE Ophthalmic Anti-Inflammatory Agents, NSAIDs
Flurbiprofen Sodium OCUFEN Diclofenac Sodium VOLTAREN Ketorolac Tromethamine ACULAR Ophthalmic Antiviral Agents
Trifluridine Ophthalmic Solution VIROPTIC Ophthalmic Beta Blockers
23
Levobunolol BETAGAN Timolol TIMOPTIC Ophthalmic Miotic Agents
Brimonidine ALPHAGAN ALPHAGAN P
Dorzolamide TRUSOPT Dorzolamide/Timolol COSOPT Echothiophate Iodide PHOSPHOLINE IODIDE Pilocarpine PILOCAR
OCUSERT NOT COVERED Ophthalmic Mydriatic Agents
Atropine Sulfate ISOPTO ATROPINE Dipivefrin PROPINE Tropicamide MYDRIACYL Ophthalmic Sulfonamide Agents
Sulfacetamide BLEPH-10 SODIUM SULAMYD Sulfacetamide 10%/Prednisolone 0.2% BLEPHAMIDE Sulfacetamide 10%/Prednisolone 0.5% METIMYD Miscellaneous Ophthalmic Agents
Ketotifen ZADITOR OTC, ALAWAY Latanoprost XALATAN Naphazoline ALBALON Naphazoline/Pheniramine NAPHCON-A Otic Anti-Infective Agents
Acetic Acid VOSOL Acetic Acid 2% DOMEBORO Acetic Acid 2%/Hydrocortisone 1% VOSOL HC Hydrocortisone/Neomycin/Polymyxin CORTISPORIN Ofloxacin FLOXIN OTIC Miscellaneous Otic Agents Benzocaine/Antipyrine AURALGAN Carbamide Peroxide/Glycerin DEBROX
Inhaled/Oral EENT Agents
Inhaled Nasal Agents
Fluticasone, Nasal FLONASE Triamcinolone, Nasal NASACORT QL Ipratropium, Nasal ATROVENT, LIMITED TO #2 DEVICES/MONTH Carbonic Anhydrase Inhibitor Agents
Acetazolamide DIAMOX Acetazolamide SA DIAMOX SEQUELS Methazolamide NEPTAZANE Local Anesthetic Agents
Benzocaine/Antipyrine Otic AURALGAN Lidocaine Solution XYLOCAINE Lidocaine, Viscous VISCOUS XYLOCAINE Triamcinolone 0.1% in Orabase KENALOG IN ORABASE
Miscellaneous EENT Agents Carbachol ISOPTO CARBACHOL Chlorhexidine Gluconate PERIDEX Cromolyn Ophthalmic Solution CROLOM Epinephrine Injection EPIPEN QL Optichamber OPTICHAMBER, LIMITED TO #2/YEAR
24
Sodium Chloride for Inhalation GENERIC Triethanolamine CERUMENEX
DIABETES AND THYROID AGENTS
Oral Diabetes Agents
Sulfonylureas
Glipizide GLUCOTROL Glipizide L.A. GLUCOTROL XL Glyburide DIABETA, GLYNASE MICRONASE Glimepiride AMARYL Chlorpropamide DIABINESE Tolazamide TOLINASE Tolbutamide ORINASE Non-Sulfonylureas
Acarbose PRECOSE Metformin GLUCOPHAGE Metformin ER GLUCOPHAGE XR Pioglitazone ACTOS SE, QL Alogliptin NESINA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF METFORMIN IN THE PAST 365 DAYS , LIMITED TO 30
TABLETS/MONTH SE, QL Sitagliptin JANUVIA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF METFORMIN IN THE PAST 365 DAYS , LIMITED TO 30
TABLETS/MONTH Combination Diabetes Agents Glipizide/Metformin METAGLIP Glyburide/Metformin GLUCOVANCE SE, QL Alogliptin/Metformin KAZANO, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL
OF METFORMIN OR ALOGLIPTIN IN THE PAST 365 DAYS, LIMITED TO 60 TABLETS/MONTH
SE, QL Sitagliptin/Metformin JANUMET, STEP THERAPY, RESTRICTED TO USE AFTER A
TRIAL OF METFORMIN OR JANUVIA IN THE PAST 365 DAYS, LIMITED TO 60 TABLETS/MONTH
SE, QL Sitagliptin/Metformin Extended Release JANUMET XR, STEP THERAPY, RESTRICTED TO USE AFTER A
TRIAL OF METFORMIN OR JANUVIA IN THE PAST 365 DAYS, LIMITED TO 30 TABLETS/MONTH EXCEPT JANUMET XR 50-1000, WHICH IS LIMITED TO 60 TABLETS/MONTH
Insulin Agents
Insulin ALL LILLY INSULINS, VIALS ONLY Insulin Lispro HUMALOG, HUMALOG MIX, VIALS AND PENS Insulin Glargine LANTUS, VIALS ONLY
Miscellaneous Diabetes Agents Glucagon GLUCAGON
Thyroid Agents Levothyroxine LEVOTHROID Liotrix THYROLAR Liothyronine CYTOMEL
25
Thyroid, Desiccated ARMOUR THYROID LEVOXYL SYNTHROID Antithyroid Agents
Methimazole TAPAZOLE Propylthiouracil PROPYLTHIOURACIL
HORMONE AGENTS
Oral Adrenal Corticosteroid Agents
Cortisone Acetate CORTONE Dexamethasone DECADRON Fludrocortisone Acetate FLORINEF Hydrocortisone Oral CORTEF Methylprednisolone MEDROL Prednisone DELTASONE ORASONE MEDROL DOSEPAK Prednisolone PEDIAPRED PRELONE
Androgen Agents
Danazol DANOCRINE Fluoxymesterone HALOTESTIN Methyltestosterone ANDROID
METANDREN
Bone Resorption Inhibitors
QL Alendronate FOSAMAX, 70MG AND 35MG LIMITED TO #4/MONTH; 5MG, 10MG, AND 40MG LIMITED TO #30/MONTH; SOLUTION LIMITED TO #300ML/MONTH FOSAMAX PLUS D NONFORMULARY
PA Calcitonin MIACALCIN NS, PA REQ
Parathyroid Hormone PA, QL Teriparatide FORTEO, PA REQ, LIMITED TO 1 PEN/MONTH
Estrogen Agents
Conjugated Estrogens PREMARIN Conjugated Estrogens, Vaginal PREMARIN VAGINAL CREAM Estradiol ESTRACE Estradiol Patches ALORA
CLIMARA ESTRADERM VIVELLE VIVELLE DOT
Estrogen/Medroxyprogesterone PREMPRO, PREMPRO LOW DOSE PREMPHASE Esterified Estrogens/ Methyltestosterone ESTRATEST, ESTRATEST HS SE Estradiol/Vaginal Ring ESTRING, STEP THERAPY, RESTRICTED TO USE AFTER A
TRIAL OF PREMARIN VAGINAL CREAM IN THE PAST 90 DAYS
26
Estrogen Agonist-Antagonists
Raloxifene EVISTA
Contraceptives Contraceptives are not a covered benefit.
Oxytocic Agents Ergonovine Maleate ERGOTRATE Methylergonovine Maleate METHERGINE
Pituitary Agents
Desmopressin DDAVP
Progestin Agents
Medroxyprogesterone CYCRIN PROVERA Norethindrone Acetate AYGESTIN NORLUTATE
GENITOURINARY AGENTS
Urinary Anti-Infective Agents
Meth/Me Blue/PA/Salol/ATP/Hyos URISED Nitrofurantoin (Tablets, Suspension
Only) FURADANTIN
Trimethoprim TRIMPEX
Urinary Anti-Spasmodic Agents
Pentosan ELMIRON Phenazopyridine PYRIDIUM
Genitourinary Smooth Muscle Relaxant Agents
Belladonna/Methylene Blue URISED Oxybutynin DITROPAN
DITROPAN XL NOT COVERED ST, QL ST, QL
Tolterodine DETROL, STEP THERAPY, LIMITED TO #60/MONTH, RESTRICTED TO USE AFTER A TRIAL OF OXYBUTININ IN THE
PAST 90 DAYS DETROL LA, STEP THERAPY, LIMITED TO #30/MONTH, RESTRICTED TO USE AFTER A TRIAL OF OXYBUTININ IN THE
PAST 90 DAYS
Parasympathomimetic (Cholinergic) Agents
Bethanechol URECHOLINE Neostigmine PROSTIGMIN Pyridostigmine MESTINON
27
TOPICAL/MUCOUS MEMBRANE AGENTS
Keratolytic Agents
Anthralin DRITHOCREME DRITHO-SCALP Podofilox CONDYLOX
Miscellaneous Skin/Mucous Membrane Agents
Aluminum Acetate BURROWS SOLUTION Aluminum Chloride Hexahydrate DRYSOL Benzoyl Peroxide, OTC Generic BENZOYL PEROXIDE, OTC GENERIC Calamine CALAMINE LOTION Calcipotriene DOVONEX Fluorouracil EFUDEX Hydrocortisone 1% Rectal PROCTOCORT Masoprocol ACTINEX PA Becaplermin REGRANEX, PA REQ PA Isotretinoin ACCUTANE, PA REQ
Topical Antibiotic Agents
Bacitracin BACITRACIN Bacitracin/Polymixin/Neomycin NEOSPORIN Clindamycin Solution CLEOCIN T Erythromycin Topical ERYGEL EMGEL T-STAT Erythromycin/Benzoyl Peroxide BENZAMYCIN Gentamicin Sulfate GARAMYCIN Mupirocin BACTROBAN Silver Sulfadiazine SILVADENE
Topical Antifungal Agents
Clotrimazole LOTRIMIN Clotrimazole/Betamethasone LOTRISONE Ciclopirox LOPROX Ketoconazole NIZORAL Miconazole Nitrate MONISTAT-DERM Nystatin MYCOSTATIN Terbinafine LAMISIL Tolnaftate TINACTIN Triamcinolone/Nystatin MYCOLOG II
Vaginal Antifungal Agents
Butoconazole FEMSTAT Clotrimazole Cream/Vaginal Tablets MYCELEX
MYCELEX G Nystatin MYCOSTATIN Miconazole Cream/Vaginal Tablets MONISTAT MONISTAT 3 Triple Sulfa Cream SULTRIN Tioconazole VAGISTAT-1
28
Vaginal Anti-Infective Agents
Metronidazole METROGEL-VAGINAL
Topical Anti-Inflammatory Agents LOW POTENCY Fluocinolone 0.025% SYNALAR Desonide TRIDESILON Hydrocortisone HYTONE Hydrocortisone Enema CORTENEMA Hydrocortisone Acetate CORTIFOAM Hydrocortisone/Pramoxine PROCTOCREAM-HC MEDIUM POTENCY Betamethasone Dipropionate DIPROSONE MAXIVATE Betamethasone Valerate 0.01% VALISONE REDUCED STRENGTH Betamethasone Valerate 0.1% VALISONE Desoximetasone Cream/Gel 0.05% TOPICORT LP Flurandrenolide CORDRAN Hydrocortisone Valerate WESTCORT Mometasone Furoate Cream ELOCON Triamcinolone ARISTOCORT
ARISTOCORT A NOT COVERED KENALOG HIGH POTENCY Betamethasone Dipropionate DIPROLENE Desoximetasone 0.25% TOPICORT Fluocinonide LIDEX LIDEX E Fluocinolone Acetonide 0.2% SYNALAR VERY HIGH POTENCY Augmented Betamethasone
Dipropionate DIPROLENE AF
Clobetasol Cream, Gel, Solution, Ointment
TEMOVATE
Diflorasone Diacetate FLORONE FLORONE-E PSORCON
Topical Antipruritic and Local Anesthetic Agents
Lidocaine (Viscous and Spray Only) XYLOCAINE Pramoxine/Hydrocortisone PROCTOFOAM HC Pramoxine EPIFOAM PA Pimecrolimus ELIDEL, PA REQ PA Tacrolimus PROTOPIC, PA REQ
Topical Antiviral Agents
Acyclovir Topical ZOVIRAX OINTMENT
Topical Miscellaneous Anti-Infective Agents
Selenium Sulfide 2.5% EXSEL SELSUN Sulfacetamide Lotion SEBIZON
29
Scabicide/Pediculicide Agents
Crotamiton EURAX Malathion OVIDE Permethrin ELIMITE NIX
MISCELLANEOUS/UNCLASSIFIED AGENTS
Electrolyte Agents
Miscellaneous Agents Calcium Acetate PHOS LO Calcium Carbonate TUMS Magnesium Oxide, OTC Generic MAGNESIUM OXIDE, OTC GENERIC Potassium Agents
Potassium Chloride 8mEq Potassium Chloride MICRO-K Potassium Chloride 10mEq Potassium Chloride KAON-CL 10 K-DUR MICRO-K 10 Potassium Chloride 20mEq Potassium Chloride K-DUR
30
Potassium Chloride Effervescent Tablets Potassium Chloride Tablets K-LYTE Potassium Chloride Tablets K-LYTE CL DS Potassium Chloride Powders Potassium Chloride Powder K-LOR Potassium Chloride Liquids Potassium Chloride Liquid KAON-CL Potassium-Removing Resins Sodium Polystyrene Sulfonate KAYEXALATE
Heavy Metal Antagonist Agents
Penicillamine CUPRIMINE
Vitamin Agents
Vitamin B-Complex Agents
Cyanocobalamin VITAMIN B12 (ORAL FORMULATIONS ONLY) Folic Acid FOLIC ACID Niacin NIACIN Pyridoxine VITAMIN B6 Thiamine VITAMIN B1 Vitamin D
Calcitriol ROCALTROL Ergocalciferol DRISDOL Vitamin K Activity Agents
Phytonadione MEPHYTON Iron Agents Ferrous Sulfate (Tablets, Liquid, Drops) FEOSOL
Diagnostic Testing Blood Glucose Supplies QL Alcohol Swabs LIMITED TO 200/MONTH Blood Glucose Monitoring Control
Solution BLOOD GLUCOSE MONITORING CONTROL SOLUTION, ROCHE
PRODUCTS (E.G., ACCU-CHEK) ONLY QL Blood Glucose Test Strips BLOOD GLUCOSE TEST STRIPS, ROCHE STRIPS (E.G., ACCU-
CHEK) ONLY, LIMITED TO 100 STRIPS/MONTH FOR MEMBERS
THAT ARE DIET-CONTROLLED OR ON ORAL AGENTS. MEMBERS ON INSULIN LIMITED TO 150 STRIPS/MONTH. LARGER QUANTITIES AVAILABLE VIA PRIOR AUTHORIZATION
Glucometers GLUCOMETERS, ROCHE METERS (E.G., ACCU-CHEK) ONLY Lancets
Alcohol And Smoking Deterrent Agents
PA Bupropion SR ZYBAN, PA REQ Disulfiram ANTABUSE PA Nicotine NICORETTE GUM, PA REQ PA NICOTINE PATCH, PA REQ (OTC PATCHES ONLY) PA NICOTROL NASAL SPRAY, PA REQ
Gout Agents
Allopurinol ZYLOPRIM
31
QL Colchicine COLCRYS, LIMITED TO 1 TABLET/DAY. PATIENTS WHO FAIL 1
TABLET/DAY MAY RECEIVE 2 TABLETS/DAY. Probenecid BENEMID
Other Medical Supplies
Limited medical supplies are available through the pharmacy benefit. For additional information, contact MedImpact at (800) 788-2949. The following exceptions should be noted:
Durable medical equipment (e.g., wheelchairs, walkers, canes, crutches) are filled through the medical benefit. Path to Health does not provide coverage for contraceptive medical supplies (e.g., diaphragms, cervical caps, condoms).
32
INDEX
—A—
ABILIFY, 13 Acarbose, 24 ACCUTANE, 27 Acetaminophen, 11 Acetaminophen/Codeine, 11 Acetaminophen/Hydrocodone, 11 Acetazolamide, 23 Acetazolamide SA, 23 Acetic Acid, 23 Acetic Acid 2%, 23 Acetic Acid 2%/Hydrocortisone 1%, 23 Acetylcysteine, 22 ACHROMYCIN V, 19 ACTIFED/CODEINE, 21 ACTIGALL, 18 ACTINEX, 27 ACTOS, 24 ACULAR, 22 Acyclovir Oral, 20 Acyclovir Topical, 28 ADALAT CC, 15 ADVAIR DISKUS 250/50 STRENGTH ONLY, 21 ADVICOR, 16 ALAWAY, 23 ALBALON, 23 Albendazole, 18 ALBENZA, 18 Albuterol, 21 Albuterol E.R., 21 Albuterol HFA, 21 Albuterol/Ipratropium, 21 Alcohol And Smoking Deterrent Agents, 30 Alcohol Swabs, 30 ALDACTAZIDE, 15 ALDACTONE, 15 ALDOMET, 15 Alendronate, 25 Allopurinol, 30 Alogliptin, 24 ALORA, 25 Alpha-Adrenergic Antagonist Antihypertensive Agents,
14 ALPHAGAN, 23 Alprazolam, 13 Aluminum Acetate, 27 Aluminum Chloride Hexahydrate, 27 ALUPENT, 22 Amantadine, 12, 20 AMARYL, 24 AMBIEN, 14 Amebicides, 18 AMERGE, 10
Aminoglycosides, 18 Aminophylline 150mg/5ml, 22 Aminophylline Suppositories, 22 Amiodarone, 14 Amitriptyline, 12 Amlodipine, 15 Amoxapine, 12 Amoxicillin, 19 Amoxicillin/Clarithromycin/Lansoprazole, 20 Amoxicillin/Potassium Clavulanate, 19 AMOXIL, 19 Ampicillin, 19 Amylase/Lipase/Protease, 17 ANAFRANIL, 13 Analgesic and Anti-Inflammatory Agents, 10 ANAPROX, 10 ANAPROX DS, 10 Androgen Agents, 25 ANDROID, 25 Angiotensin Converting Enzyme Inhibitor Agents, 14 Angiotensin Receptor Blocker Agents, 14 ANTABUSE, 30 Antacid Mg OH/Al OH, 17 Antacid Mg OH/Al OH/Simethicone, 17 Anthralin, 27 Antiarrhythmic Agents, 14 Antibiotic Agents, 18 Anticonvulsant Agents, 11 Antidiarrheal Agents, 16 Antidysrhythmic Drug Agents, 14 Antiemetic Agents, 17 Antifungal Agents, 19 Antihelmintic Agents, 18 Antihistamine Agents, 20 Antihistamine/Decongestant Agents, 21 Antihistamine/Decongestant Combination Agents, 21 Antihypertensive Agents, 14 ANTI-INFECTIVE AGENTS, 18 Antilipemic Agents, 16 Antimalarial Agents, 20 Antimanic Agents, 13 Antimuscarinic/Antispasmodic Agents, 17 Antiparkinsonian Agents, 12 Antiplatelet Agents, 16 Antipsychotic Agents, 13 Antipsychotic/SSRI Combination Agents, 13 Antithyroid Agents, 25 Antituberculosis Agents, 20 Antitussive Agents, 21 Anti-Ulcer Eradication Agents, 20 Antiulcer/Antipeptic Agents, 17 ANTIVERT, 17 Antiviral Agents, Other, 20 APAP/Dichloralphenazone/Isometheptene, 10 APRESOLINE, 15
33
ARAVA, 10 ARICEPT, 11 Aripiprazole, 13 ARISTOCORT, 28 ARMOUR THYROID, 25 ARTANE, 12 Asenapine, 13 ASENDIN, 12 ASMANEX, 22 ASPIRIN, 10 Aspirin, 10 Aspirin EC, 10 Asthma/COPD Agents, 21 ATARAX, 13, 21 Atenolol, 14 Atenolol/Chlorthalidone, 15 ATIVAN, 13 Atorvastatin, 16 Atovaquone/Proguanil, 20 Atropine Sulfate, 23 ATROVENT, 23 ATROVENT HFA, 21 Attapulgite, 16 Augmented Betamethasone Dipropionate, 28 AUGMENTIN, 19 AURALGAN, 23 AVAPRO, 14 AVELOX, 19 AYGESTIN, 26 Azithromycin, 19 AZULFIDINE, 18
—B—
Bacitracin, 22, 27 Bacitracin/Polymixin/Neomycin, 27 Baclofen, 12 BACTRIM, 19 BACTROBAN, 27 Barbiturate Anticonvulsants, 11 Becaplermin, 27 Beclomethasone Inhaler, 22 Belladonna/Methylene Blue, 26 Belladonna/Phenobarbital, 17 BENADRYL, 20 Benazepril, 14 Benazepril/HCTZ, 15 BENEMID, 31 BENICAR, 14 BENICAR HCT, 15 BENTYL, 17 BENZAMYCIN, 27 Benzocaine/Antipyrine, 23 Benzocaine/Antipyrine Otic, 23 Benzodiazepine Anticonvulsants, 11 Benzodiazepines, 13 Benzonatate, 21 BENZOYL PEROXIDE, OTC GENERIC, 27 Benzoyl Peroxide, OTC Generic, 27
Benztropine Mesylate, 12 Beta-Adrenergic Antagonist Agents, 14 BETAGAN, 23 Betamethasone Dipropionate, 28 Betamethasone Valerate 0.01%, 28 Betamethasone Valerate 0.1%, 28 BETAPACE, 14 Bethanechol, 26 BIAXIN, 19 BILTRICIDE, 18 Bisacodyl Suppositories, 18 Bismuth Subsalicylate, 16 Bisoprolol/HCTZ, 15 BLEPH-10, 23 BLEPHAMIDE, 23 Blood Agents, 16 Blood Glucose Monitoring Control Solution, 30 Blood Glucose Supplies, 30 Blood Glucose Test Strips, 30 Bone Resorption Inhibitors, 25 Bowel Evacuant Agents, 17 Bowel Evacuation Prep Kits, 17 BRETHINE, 22 BRICANYL, 22 Brimonidine, 23 BROMFED, 21 Bromocriptine, 12 Bromphen/Pseudoephedrine, 21 Budesonide, 18 Bumetanide, 15 BUMEX, 15 Bupropion, 13 Bupropion SR, 13, 30 Bupropion XL, 13 BURROWS SOLUTION, 27 BUSPAR, 13 Buspirone, 13 Butalbital/APAP/Caffeine, 10 Butalbital/APAP/Caffeine/Codeine, 11 Butalbital/Aspirin/Caffeine, 10 Butalbital/Aspirin/Caffeine/Codeine, 11 Butoconazole, 27 Butorphanol NS, 11
—C—
CAFERGOT, 10 Calamine, 27 CALAMINE LOTION, 27 CALAN, 15 CALAN SR, 15 Calcipotriene, 27 Calcitonin, 25 Calcitriol, 30 Calcium Acetate, 29 Calcium Carbonate, 29 Calcium Channel Blocking Agents, 15 CAPOTEN, 14 CAPOZIDE, 15
34
Captopril, 14 Captopril/HCTZ, 15 CARAFATE, 17 Carbachol, 23 Carbamazepine, 11 Carbamazepine Extended Release, 11 Carbamide Peroxide/Glycerin, 23 Carbidopa/Levodopa, 12 Carbidopa/Levodopa CR, 12 Carbonic Anhydrase Inhibitor Agents, 23 Cardiac Glycoside Agents, 16 CARDIOQUIN, 14 CARDIOVASCULAR/BLOOD AGENTS, 14 CARDIZEM, 15 CARDIZEM SR, 15 CARDURA, 15 Carisoprodol, 12 CARTIA XT, 15 Carvedilol, 14 CATAPRES, 15 CECLOR, 18 Cefaclor, 18 Cefadroxil, 19 Cefdinir, 19 Cefixime, 19 CEFTIN, 19 Cefuroxime, 19 CELEBREX, 10 Celecoxib, 10 CELEXA, 12 CENTRAL NERVOUS SYSTEM AGENTS, 10 Centrally Acting Antihypertensive Agents, 15 Cephalexin, 19 Cephalosporins, 18 CEPHULAC, 18 CERUMENEX, 24 Cetirizine OTC, 20 CETIRIZINE, OTC, 20 Chloral Hydrate, 13 Chlordiazepoxide, 13 Chlordiazepoxide/Clidinium, 17 Chlorhexidine Gluconate, 23 CHLOROQUINE PHOSPHATE, 20 Chloroquine Phosphate, 20 Chlorpheniramine, 20 Chlorpromazine, 13 Chlorpropamide, 24 Chlorthalidone, 15 CHLORTRIMETON, 20 Chlorzoxazone, 12 Cholestyramine/Aspartame, 16 Cholestyramine/Sucrose, 16 CHRONULAC, 18 Ciclopirox, 27 Cilostazole, 16 Cimetidine, 18 CIN-QUIN, 14 CIPRO, 19 Ciprofloxacin tablets, 19
Citalopram, 12 Clarithromycin, 19 CLEOCIN, 19 CLEOCIN T, 27 CLIMARA, 25 Clindamycin, 19 Clindamycin Solution, 27 CLINORIL, 10 Clobetasol Cream, Gel, Solution, Ointment, 28 Clofazimine, 20 Clomipramine, 13 Clonazepam, 11 Clonidine, 15 Clopidogrel, 16 Clorazepate, 13 Clotrimazole, 19, 27 Clotrimazole Cream/Vaginal Tablets, 27 Clotrimazole/Betamethasone, 27 Clozapine, 13 CLOZARIL, 13 Coagulants and Anticoagulants, 16 Codeine/Aspirin, 11 Codeine/Chlorpheniramine/Pseudoephedrine, 21 COGENTIN, 12 COLACE, 18 Colchicine, 31 COLCRYS, 31 COLYTE, 17 Combination Alpha-Beta Antagonist Agents, 14 Combination Antihypertensive Agents, 15 Combination Diabetes Agents, 24 COMBIVENT RESPIMAT, 21 COMPAZINE, 17 CONDYLOX, 27 Conjugated Estrogens, 25 Conjugated Estrogens, Vaginal, 25 CORDARONE, 14 CORDRAN, 28 COREG, 14 CORGARD, 14 CORTEF, 25 CORTENEMA, 28 CORTIFOAM, 28 Cortisone Acetate, 25 CORTISPORIN, 23 CORTISPORIN OPHTHALMIC, 22 CORTONE, 25 COSOPT, 23 COUMADIN, 16 COZAAR, 14 CREON, 17 CROLOM, 23 Cromolyn Ophthalmic Solution, 23 Crotamiton, 29 CUPRIMINE, 30 Cyanocobalamin, 30 Cyclobenzaprine, 12 CYCRIN, 26 CYMBALTA, 12
35
Cyproheptadine, 20 CYTOMEL, 24 CYTOTEC, 17
—D—
DALMANE, 13 Danazol, 25 DANOCRINE, 25 DANTRIUM, 12 Dantrolene Sodium, 12 DAPSONE, 20 Dapsone, 20 DARAPRIM, 20 DDAVP, 26 DEBROX, 23 DECADRON, 25 DECONAMINE SR, 21 Decongestants, 21 DELTASONE, 25 DELZICOL, 18 DEPAKENE, 11 DEPAKOTE, 11 Desipramine, 12 Desmopressin, 26 Desonide, 28 Desoximetasone 0.25%, 28 Desoximetasone Cream/Gel 0.05%, 28 DESYREL, 13 DETROL, 26 DETROL LA, 26 Dexamethasone, 25 Dexamethasone/Polymyxin/Neomycin, 22 Dexchlorpheniramine, 20 Dextromethorphan, 21 DIABETA, 24 DIABETES AND THYROID AGENTS, 24 DIABINESE, 24 Diagnostic Testing, 30 DIAMOX, 23 DIAMOX SEQUELS, 23 Diazepam, 13 DIBENZYLINE, 15 Diclofenac Sodium, 10, 22 Dicloxacillin, 19 Dicyclomine, 17 Diflorasone Diacetate, 28 DIFLUCAN, 19 Digestive Enzymes, 17 Digoxin, 16 Dihydroergotamine, 10 DILANTIN, 11 DILATRATE SR, 16 DILAUDID, 11 Diltiazem, 15 Diltiazem CD, 15 Diltiazem SR, 15 DIOVAN, 14 DIOVAN HCT, 15
DIPENTUM, 18 Diphenhydramine, 20 Diphenoxylate/Atropine, 17 Dipivefrin, 23 DIPROLENE, 28 DIPROLENE AF, 28 DIPROSONE, 28 Dipyridamole, 16 DISALCID, 10 Disopyramide, 14 Disopyramide CR, 14 Disulfiram, 30 DITROPAN, 26 Divalproex Sodium, 11 Divalproex Sodium Extended Release, 11 Docusate Sodium Capsules, 18 DOMEBORO, 23 Donepezil, 11 DONNATAL, 17 Dorzolamide, 23 Dorzolamide/Timolol, 23 DOVONEX, 27 Doxazosin Mesylate, 15 Doxepin, 12 DOXYCYCLINE, 19 DRISDOL, 30 DRITHOCREME, 27 DRITHO-SCALP, 27 Drugs for Pheochromocytoma, 15 DRYSOL, 27 DULCOLAX, 18 DULERA, 21 Duloxetine, 12 DURICEF, 19 DYAZIDE, 15 DYNAPEN, 19 DYRENIUM, 15
—E—
Echothiophate Iodide, 23 ECOTRIN, 10 EES, 19 EFFEXOR, 12 EFFEXOR XR, 12 EFFIENT, 16 EFLONE, 22 EFUDEX, 27 ELAVIL, 12 Electrolyte Agents, 29 Eletriptan, 10 ELIDEL, 28 ELIMITE, 29 ELMIRON, 26 ELOCON, 28 EMGEL, 27 EMPIRIN #2, #3, #4, 11 Enalapril, 14 Enalapril/HCTZ, 15
36
ENDAL, 22 ENDAL-HD, 21 Enema, 17 Enoxaparin, 16 ENTOCORT EC, 18 EPIFOAM, 28 Epinephrine Injection, 23 EPIPEN, 23 Ergocalciferol, 30 Ergonovine Maleate, 26 Ergotamine/Caffeine, 10 ERGOTRATE, 26 ERYGEL, 27 ERYPED SUSPENSION, 19 ERY-TAB, 19 ERYTHROCIN, 19 Erythromycin Base, 19, 22 Erythromycin Ethylsuccinate, 19 Erythromycin Stearate, 19 Erythromycin Topical, 27 Erythromycin/Benzoyl Peroxide, 27 Erythromycin/Sulfisoxazole, 19 ESGIC, 10 ESGIC PLUS, 10 ESKALITH, 13 Esterified Estrogens/Methyltestosterone, 25 ESTRACE, 25 ESTRADERM, 25 Estradiol, 25 Estradiol Patches, 25 Estradiol/Vaginal Ring, 25 ESTRATEST, 25 ESTRATEST HS, 25 ESTRING, 25 Estrogen Agents, 25 Estrogen Agonist-Antagonists, 26 Estrogen/Medroxyprogesterone, 25 Ethambutol, 20 Etodolac, 10 Etodolac Extended Release, 10 EURAX, 29 EVISTA, 26 Expectorant Agents, 22 EXSEL, 28 Eye, Ear, Nose and Throat (EENT) Preparations, 22
—F—
Famciclovir, 20 Famotidine, 18 FAMVIR, 20 FELDENE, 10 Felodipine, 15 FEMSTAT, 27 FEOSOL, 30 Ferrous Sulfate, 30 FEXOFENADINE, 20 Fexofenadine, 20 FIORICET, 10
FIORICET/CODEINE, 11 FIORINAL, 10 FIORINAL/CODEINE, 11 FLAGYL, 18, 19 Flecainide, 14 FLEET ENEMA, 17 FLEET PHOSPHO-SODA, 17 FLEET PREP KIT 1, 17 FLEET PREP KIT 2, 17 FLEET PREP KIT 3, 17 FLEXERIL, 12 FLONASE, 23 FLORINEF, 25 FLORONE, 28 FLORONE-E, 28 FLOXIN OTIC, 23 Fluconazole, 19 Fludrocortisone Acetate, 25 FLUMADINE, 20 Fluocinolone, 28 Fluocinolone 0.025%, 28 Fluocinolone Acetonide 0.2%, 28 Fluorometholone, 22 Fluorouracil, 27 Fluoxetine Capsules, 12 Fluoxymesterone, 25 Fluphenazine, 13 Flurandrenolide, 28 Flurazepam, 13 Flurbiprofen Sodium, 22 Fluticasone, Nasal, 23 Fluvoxamine, 12 FML, 22 FML FORTE, 22 FOLIC ACID, 30 Folic Acid, 30 FORADIL, 21 Formoterol, 21 FORTEO, 25 FOSAMAX, 25 FULVICIN P/G, 19 FURADANTIN, 26 Furazolidone, 18 Furosemide, 15 FUROXONE, 18
—G—
Gabapentin, 11 GABITRIL, 11 Gallstone Solubilizing Agents, 18 GANTRISIN, 19 GARAMYCIN, 22, 27 GASTROINTESTINAL AGENTS, 16 Gastrointestinal Stimulant Agents, 18 Gemfibrozil, 16 GENITOURINARY AGENTS, 26 Genitourinary Smooth Muscle Relaxant Agents, 26 Gentamicin, 22
37
Gentamicin Sulfate, 27 Gentamicin/Prednisolone, 22 GEODON, 13 Glimepiride, 24 Glipizide, 24 Glipizide L.A., 24 Glipizide/Metformin, 24 GLUCAGON, 24 Glucagon, 24 Glucometers, 30 GLUCOPHAGE, 24 GLUCOPHAGE XR, 24 GLUCOTROL, 24 GLUCOTROL XL, 24 GLUCOVANCE, 24 Glyburide, 24 Glyburide/Metformin, 24 GLYNASE, 24 Gout Agents, 30 Griseofulvin Ultramicrosize, 19 GRIS-PEG, 19 GUAIFED-PD, 21 Guaifenesin, 22 Guaifenesin/Codeine, 21 Guaifenesin/Codeine/Pseudoephedrine, 21 Guaifenesin/Dextromethorphan, 22 Guaifenesin/Phenylephrine, 22 Guaifenesin/Pseudoephedrine, 21, 22 Guanfacine, 15
—H—
H2 Antagonist Agents, 18 HALCION, 13 HALDOL, 13 HALDOL DECANOATE (VIALS ONLY), 13 Haloperidol, 13 HALOTESTIN, 25 Heavy Metal Antagonist Agents, 30 HELIDAC, 20 Hemorheologic Agents, 16 HISTUSSIN HC, 21 HORMONE AGENTS, 25 HUMALOG (VIALS AND PENS), 24 HUMALOG MIX (VIALS AND PENS), 24 Hydantoin Anticonvulsants, 11 Hydralazine, 15 Hydrochlorothiazide (HCTZ), 15 Hydrocortisone, 28 Hydrocortisone 1% Rectal Cream, 27 Hydrocortisone Acetate, 28 Hydrocortisone Enema, 28 Hydrocortisone Oral, 25 Hydrocortisone Valerate, 28 Hydrocortisone/Neomycin/Polymyxin, 22, 23 Hydrocortisone/Pramoxine, 28 HYDRODIURIL, 15 Hydromorphone, 11 Hydroxychloroquine, 20
Hydroxyzine, 13, 21 Hydroxyzine Pamoate, 14, 21 HYGROTON, 15 Hyoscyamine Sulfate, 17 HYTONE, 28 HYTRIN, 15 HYZAAR, 15
—I—
Ibuprofen, 10 ILOTYCIN, 22 IMDUR, 16 Imipramine, 12 IMITREX, 10 IMODIUM, 17 Indapamide, 15 INDERAL, 14 INDERAL LA, 14 INDOCIN, 10 INDOCIN SR, 10 Indomethacin, Sustained Release, 10 INFLAMASE, 22 INFLAMASE FORTE, 22 Inhaled Nasal Agents, 23 Inhaled Oral Corticosteroid Agents, 22 Inhaled Sympathomimetic (Adrenergic) Agents, 21 Inhaled/Oral EENT Agents, 23 Insulin, 24 Insulin Agents, 24 Insulin Glargine, 24 Insulin Lispro, 24 Iodoquinol, 20 Iodoquinol (Diiodohydroxyquin), 18 Ipratropium, 21 Ipratropium, Nasal, 23 Irbesartan, 14 Iron Agents, 30 ISONIAZID, 20 Isoniazid, 20 ISOPTO ATROPINE, 23 ISOPTO CARBACHOL, 23 ISORDIL, 16 Isosorbide Dinitrate, 16 Isosorbide Dinitrate ER, 16 Isosorbide Dinitrate SR, 16 Isosorbide Mononitrate, 16 Isotretinoin, 27
—J—
JANUMET, 24 JANUMET XR, 24 JANUVIA, 24
—K—
Kaolin/Pectin, 17 KAON-CL, 30
38
KAON-CL 10, 29 KAOPECTATE, 17 KAYEXALATE, 30 KAZANO, 24 K-DUR, 29 K-DUR, 29 KEFLEX, 19 KENALOG, 28 KENALOG IN ORABASE, 23 KEPPRA, 11 Keratolytic Agents, 27 Ketoconazole, 19, 27 Ketoprofen, 10 Ketorolac Tromethamine, 22 Ketotifen, 23 KLONOPIN, 11 K-LOR, 30 K-LYTE, 30 K-LYTE CL DS, 30
—L—
Labetalol, 14 Lactulose, 18 LAMICTAL, 11 LAMISIL, 19, 27 Lamotrigine, 11 LAMPRENE, 20 Lancets, 30 LANOXIN, 16 Lansoprazole 15mg OTC, 17 LANTUS (VIALS ONLY), 24 LARIAM, 20 LASIX, 15 Latanoprost, 23 Laxative Agents, 18 Leflunomide, 10 Leprostatic Agents, 20 Leukotriene Receptor Antagonists, 22 LEVBID, 17 Levetiracetam, 11 Levobunolol, 23 LEVOTHROID, 24 Levothyroxine, 24 LEVOXYL, 25 LEVSIN, 17 LEVSIN SL, 17 LIBRIUM, 13 LIDEX, 28 LIDEX E, 28 Lidocaine, 28 Lidocaine Solution, 23 Lidocaine, Viscous, 23 LILLY INSULINS (VIALS ONLY), 24 LIORESAL, 12 Liothyronine, 24 Liotrix, 24 LIPITOR, 16 Lisinopril, 14
Lisinopril/HCTZ, 15 Lithium Carbonate, 13 LITHOBID, 13 Local Anesthetic Agents, 23 LODINE, 10 LODINE XL, 10 LOMOTIL, 17 LONITEN, 15 Loop Diuretics, 15 Loperamide, 17 LOPID, 16 LOPRESSOR, 14 LOPROX, 27 Loratadine OTC, 20 LORATADINE, OTC, 20 Lorazepam, 13 Losartan, 14 Losartan/HCTZ, 15 LOTENSIN, 14 LOTENSIN HCT, 15 LOTRIMIN, 27 LOTRISONE, 27 Lovastatin, 16 LOVENOX, 16 Loxapine, 13 LOXITANE, 13 LOZOL, 15 LUDIOMIL, 12 LUVOX, 12
—M—
M.A.O. Inhibitor Agents, 12 MAALOX, 17 MAALOX TC, 17 Macrolide Antibiotic Agents, 19 MAGNESIUM OXIDE, OTC GENERIC, 29 Magnesium Oxide, OTC Generic, 29 MALARONE, 20 Malathion, 29 Maprotiline, 12 Masoprocol, 27 MAXAIR, 21 MAXAIR AUTOHALER, 21 MAXALT, 10 MAXALT MLT, 10 MAXITROL, 22 MAXIVATE, 28 MAXZIDE 50, 15 MEBARAL, 11 Mebendazole, 18 Meclizine, 17 MEDROL, 25 MEDROL DOSEPAK, 25 Medroxyprogesterone, 26 Mefloquine, 20 MELLARIL, 13 Meloxicam Tablets, 10 Mephobarbital, 11
39
MEPHYTON, 30 Mesalamine, 18 MESTINON, 26 METAGLIP, 24 METANDREN, 25 Metaproterenol Oral, 22 Metformin, 24 Metformin ER, 24 Meth/Me Blue/PA/Salol/ATP/Hyos, 26 Methazolamide, 23 METHERGINE, 26 Methimazole, 25 Methocarbamol, 12 Methyldopa, 15 Methylergonovine Maleate, 26 Methylprednisolone, 25 Methyltestosterone, 25 METIMYD, 23 Metoclopramide, 17, 18 Metolazone, 15 Metoprolol Succinate, 14 Metoprolol Tartrate, 14 METROGEL-VAGINAL, 28 Metronidazole, 18, 19, 28 MEVACOR, 16 Mexiletine, 14 MEXITIL, 14 MIACALCIN NS, 25 MICARDIS, 14 Miconazole Cream/Vaginal Tablets, 27 Miconazole Nitrate, 27 MICRO-K, 29 MICRO-K 10, 29 MICRONASE, 24 MIDRIN, 10 Migraine Agents, 10 MIGRANAL, 10 MINIPRESS, 15 MINOCIN, 19 Minocycline, 19 Minoxidil, 15 MIRAPEX, 12 Mirtazapine, 13 Miscellaneous Agents, 29 Miscellaneous Analgesics, 11 Miscellaneous Antibiotic Agents, 19 Miscellaneous Anticonvulsants, 11 Miscellaneous Antidepressant Agents, 12 Miscellaneous Antihistamine Agents, 21 Miscellaneous Anxiolytics, Sedatives, and Hypnotics, 13 Miscellaneous Arthritis Agents, 10 Miscellaneous Central Nervous System Agents, 11 Miscellaneous Diabetes Agents, 24 Miscellaneous EENT Agents, 23 Miscellaneous Gastrointestinal Agents, 18 Miscellaneous Gastrointestinal Supplies, 18 Miscellaneous Ophthalmic Agents, 23 Miscellaneous Otic Agents, 23 Miscellaneous Skin/Mucous Membrane Agents, 27
MISCELLANEOUS/UNCLASSIFIED AGENTS, 29 Misoprostol, 17 MOBAN, 13 MOBIC (TABLETS ONLY), 10 Molindone, 13 Mometasone Furoate Cream, 28 Mometasone Inhaler, 22 Mometasone/Formoterol, 21 MONISTAT, 27 MONISTAT 3, 27 MONISTAT-DERM, 27 Montelukast, 22 Morphine, 11 Morphine SR, 11 MOTRIN, 10 Moxifloxacin, 19 MS CONTIN/ORAMORPH SR, 11 MSIR, 11 Mucolytic Agents, 22 MUCOMYST, 22 Mupirocin, 27 Muscle Relaxant Agents, 12 MYAMBUTOL, 20 MYCELEX, 27 MYCELEX G, 27 MYCELEX TROCHE, 19 MYCIFRADIN, 18 MYCOBUTIN, 20 MYCOLOG II, 27 MYCOSTATIN, 19, 27 MYDRIACYL, 23 MYLANTA I, 17 MYLANTA II, 17 MYLICON, 17 MYSOLINE, 11
—N—
Nabumetone, 10 Nadolol, 14 Naloxone, 11 Naltrexone, 11 Naphazoline, 23 Naphazoline/Pheniramine, 23 NAPHCON-A, 23 NAPROSYN, 10 Naproxen, 10 Naproxen Sodium, 10 Naratriptan, 10 NARCAN, 11 Narcotic Antitussive Agents, 21 Narcotic Withdrawal Therapy Agents, 11 NARDIL, 12 NASACORT, 23 NAVANE, 13 Nefazodone, 13 Neomycin Sulfate, 18 Neomycin/Gramicidin/Polymyxin, 22 NEOSPORIN, 27
40
NEOSPORIN OPHTHALMIC, 22 Neostigmine, 26 NEPTAZANE, 23 NESINA, 24 NEURONTIN, 11 NIACIN, 16, 30 Niacin, 16, 30 Niacin, Delayed Release, 16 Niacin/Lovastatin, 16 NIASPAN, 16 NICORETTE GUM, 30 Nicotine, 30 NICOTINE PATCH, 30 NICOTROL NASAL SPRAY, 30 Nifedipine, Sustained Release, 15 NITRO-DUR, 16 Nitrofurantoin, 26 Nitroglycerin Ointment, 16 Nitroglycerin Patches, 16 Nitroglycerin Spray, 16 Nitroglycerin Sublingual, 16 NITROL, 16 NITROLINGUAL SPRAY, 16 NITROSTAT SL, 16 NIX, 29 NIZORAL, 19, 27 NOCTEC, 13 Non-Narcotic Antitussive Agents, 21 Non-Sedating Single Entity Agents, 20 Non-Steroidal Anti-Inflammatory Agents, 10 Non-Sulfonylureas, 24 NORCO, 11 Norethindrone Acetate, 26 NORFLEX, 12 NORGESIC, 12 NORLUTATE, 26 NORMODYNE, 14 NORPACE, 14 NORPACE CR, 14 NORPRAMIN, 12 Nortriptyline, 12 NORVASC, 15 NOVAHISTINE DH, 21 NOVAHISTINE EXPECTORANT, 21 Nystatin, 19, 27
—O—
OCUFEN, 22 OCUFLOX, 22 Ofloxacin, 22, 23 Olanzapine, 13 Olanzapine/Fluoxetine HCl, 13 Olmesartan, 14 Olmesartan/HCTZ, 15 Olsalazine, 18 Omeprazole 20mg and 40mg, 17 Omeprazole Magnesium, 17 OMNICEF, 19
Ondansetron ODT Tablets, 17 Ondansetron Solution, 17 Ondansetron Tablets, 17 Ophthalmic Antibiotic Agents,, 22 Ophthalmic Anti-Inflammatory Agents, Corticosteroid, 22 Ophthalmic Anti-Inflammatory Agents, NSAIDs, 22 Ophthalmic Antiviral Agents, 22 Ophthalmic Beta Blockers, 22 Ophthalmic Miotic Agents, 23 Ophthalmic Mydriatic Agents, 23 Ophthalmic Sulfonamide Agents, 23 Opiate Agonists, 10 Opiate Antagonists, 11 OPTICHAMBER, 23 Optichamber, 23 Oral Adrenal Corticosteroid Agents, 25 Oral Colon Lavage Solution, 17 Oral Contraceptive Agents, 26 Oral Diabetes Agents, 24 Oral Saline Laxative, 17 Oral Sympathomimetic (Adrenergic) Agents, 21 ORAP, 13 ORASONE, 25 ORINASE, 24 Orphenadrine Citrate, 12 Orphenadrine/Aspirin/Caffeine, 12 ORUVAIL, 10 Oseltamivir, 20 Ostomy Supplies, 18 Other Medical Supplies, 31 Otic Anti-Infective Agents, 23 OVIDE, 29 Oxcarbazepine, 11 Oxybutynin, 26 Oxycodone, 11 Oxycodone/Acetaminophen, 11 Oxycodone/Aspirin, 11 OXYCONTIN, 11 OXYFAST, 11 OXYIR, 11 Oxytocic Agents, 26
—P—
PAMELOR, 12 PANCREAZE, 18 PANCRELIPASE 5,000, 17 Pantoprazole, 17 PARAFON DSC, 12 Parasympathomimetic (Cholinergic) Agents, 26 Parathyroid Hormone, 25 PAREPECTOLIN, 16 PARLODEL, 12 PARNATE, 12 Paroxetine, 12 Pasugrel, 16 PAXIL, 12 PCE, 19 PEDIAPRED, 25
41
PEDIAZOLE, 19 PEN VK, 19 Penicillamine, 30 Penicillin VK, 19 Penicillins, 19 Pentosan, 26 Pentoxifylline, 16 PEPCID, 18 PEPTO BISMOL, 16 PERCOCET, 11 PERCODAN, 11 PERIACTIN, 20 PERIDEX, 23 Permethrin, 29 Perphenazine, 13 PERSANTINE, 16 Phenazopyridine, 26 Phenelzine, 12 PHENERGAN, 14, 17, 21 PHENERGAN VC, 22 PHENERGAN VC/CODEINE, 21 PHENERGAN W/DEXTROMETHORPHAN, 21 PHENERGAN/CODEINE, 21 PHENOBARBITAL, 11 Phenobarbital, 11 Phenoxybenzamine, 15 Phenylephrine/Guaifenesin, 22 Phenylephrine/Hydrocodone/Chlorpheniramine, 21 Phenylephrine/Promethazine, 22 PHENYTEK, 11 Phenytoin, 11 PHOS LO, 29 PHOSPHOLINE IODIDE, 23 Phytonadione, 30 PILOCAR, 23 Pilocarpine, 23 Pimecrolimus, 28 Pimozide, 13 Pindolol, 14 Pioglitazone, 24 Pirbuterol Acetate, 21 Piroxicam, 10 Pituitary Agents, 26 PLAQUENIL, 20 PLAVIX, 16 PLENDIL, 15 PLETAL, 16 Podofilox, 27 POLARAMINE, 20 Polymixin B Sulfate/TMP, 22 POLYTRIM, 22 Potassium Agents, 29 Potassium Chloride, 29 Potassium Chloride 10mEq, 29 Potassium Chloride 20mEq, 29 Potassium Chloride 8mEq, 29 Potassium Chloride Effervescent Tablets, 30 Potassium Chloride Liquid, 30 Potassium Chloride Liquids, 30
Potassium Chloride Powder, 30 Potassium Chloride Powders, 30 Potassium Chloride Tablets, 30 Potassium Iodide, 22 Potassium-Removing Resins, 30 Potassium-Sparing Diuretics, 15 Pramipexole, 12 Pramoxine, 28 Pramoxine/Hydrocortisone, 28 PRAVACHOL, 16 Pravastatin, 16 Praziquantel, 18 Prazosin, 15 PRECOSE, 24 PRED FORTE, 22 PRED MILD OPHTHALMIC, 22 PRED-G, 22 Prednisolone, 25 Prednisolone Acetate, 22 Prednisolone Phosphate, 22 Prednisone, 25 PRELONE, 25 PREMARIN, 25 PREMARIN VAGINAL CREAM, 25 PREMPHASE, 25 PREMPRO, 25 PREMPRO LOW DOSE, 25 PREVACID 24HR, 17 PREVPAC, 20 PRILOSEC 20MG AND 40MG, 17 PRILOSEC OTC, 17 PRIMAQUINE, 20 Primaquine, 20 Primidone, 11 PRINCIPEN, 19 PRINIVIL, 14 PRINZIDE, 15 Probenecid, 31 Procainamide, 14 Procainamide SR, 14 PROCAN SR, 14 PROCANBID, 14 Prochlorperazine Maleate, 17 PROCTOCORT, 27 PROCTOCREAM-HC, 28 PROCTOFOAM HC, 28 Progestin Agents, 26 PROLIXIN, 13 Promethazine, 14, 17, 21 Promethazine/Codeine, 21 Promethazine/Dextromethorphan, 21 Promethazine/Phenylephrine/Codeine, 21 PRONESTYL, 14 Propafenone, 14 PROPINE, 23 Propranolol, 14 Propranolol LA, 14 PROPYLTHIOURACIL, 25 Propylthiouracil, 25
42
PROSTIGMIN, 26 PROTONIX, 17 PROTOPIC, 28 Protriptyline, 12 PROVENTIL, 21 PROVENTIL HFA, 21 PROVENTIL REPETABS, 21 PROVERA, 26 PROZAC CAPSULES, 12 Pseudoephedrine, 21 Pseudoephedrine/Chlorpheniramine, 21 PSORCON, 28 Psychotherapeutic Agents, 12 PYRAZINAMIDE, 20 Pyrazinamide, 20 PYRIDIUM, 26 Pyridostigmine, 26 Pyridoxine, 30 Pyrimethamine, 20
—Q—
QUESTRAN, 16 QUESTRAN LIGHT, 16 Quetiapine, 13 QUINAGLUTE, 14 QUINIDEX, 14 Quinidine Gluconate, 14 Quinidine Polygalacturonate, 14 Quinidine Sulfate, 14 Quinidine Sulfate SR, 14 QUININE, 20 Quinine, 20 Quinolones, 19 QVAR REDIHALER, 22
—R—
Raloxifene, 26 Ranitidine, 18 REGLAN, 17, 18 REGRANEX, 27 RELAFEN, 10 RELENZA, 20 RELPAX, 10 REMERON, 13 REQUIP, 12 RESCON GC, 22 Reserpine, 14 Respiratory Smooth Muscle Relaxant Agents, 22 RESPIRATORY/EENT AGENTS, 20 RESTORIL, 13 REVIA, 11 Rifabutin, 20 RIFADIN, 20 Rifampin, 20 Rimantadine, 20 RISPERDAL, 13 Risperidone, 13
Rizatriptan, 10 ROBAXIN, 12 ROBITUSSIN, 22 ROBITUSSIN A-C, 21 ROBITUSSIN DAC, 21 ROBITUSSIN DM, 22 ROCALTROL, 30 Ropinirole, 12 ROWASA, 18 RYTHMOL, 14
—S—
S.N.R.I. Agents, 12 S.S.R.I. Agents, 12 Salmeterol, 21 Salmeterol/Fluticasone, 21 Salsalate, 10 SAPHRIS, 13 Scabicide/Pediculicide Agents, 29 SEBIZON, 28 Selegiline, 12 Selenium Sulfide 2.5%, 28 SELSUN, 28 SENNA, 18 Sennosides, 18 SEPTRA, 19 SEREVENT, 21 SEROQUEL, 13 SERPASIL, 14 Sertraline, 12 SERZONE, 13 SILVADENE, 27 Silver Sulfadiazine, 27 Simethicone, 17 Simvastatin, 16 SINEMET, 12 SINEMET CR, 12 SINEQUAN, 12 Single Entity Alkylamine Agents, 20 Single Entity Ethanolamine Agents, 20 SINGULAIR, 22 Sitagliptin, 24 Sitagliptin/Metformin, 24 Sitagliptin/Metformin Extended Release, 24 Skeletal Muscle Relaxants, 12 SLO-BID, 22 SLO-PHYLLIN, 22 SLO-PHYLLIN 80, 22 Sodium Chloride for Inhalation, 24 Sodium Polystyrene Sulfonate, 30 SODIUM SULAMYD, 23 SOMA, 12 Sotalol, 14 Spironolactone, 15 Spironolactone/HCTZ, 15 SSKI, 22 STADOL NS, 11 STELAZINE, 13
43
Sucralfate, 17 SUDAFED, 21 Sulfacetamide, 23 Sulfacetamide 10%/Prednisolone 0.2%, 23 Sulfacetamide 10%/Prednisolone 0.5%, 23 Sulfacetamide Lotion, 28 SULFADIAZINE, 19 Sulfadiazine, 19 Sulfamethoxazole/Trimethoprim (SMZ/TMP), 19 Sulfasalazine, 18 Sulfisoxazole, 19 Sulfonamide Agents, 19 Sulfonylureas, 24 Sulindac, 10 SULTRIN, 27 Sumatriptan, 10 SUMYCIN, 19 SUPRAX, 19 SYMBYAX, 13 SYMMETREL, 12, 20 SYNALAR, 28 SYNTHROID, 25
—T—
Tacrolimus, 28 TAGAMET, 18 TAMBOCOR, 14 TAMIFLU, 20 TAPAZOLE, 25 TEGRETOL, 11 TEGRETOL XR, 11 Telmisartan, 14 Temazepam, 13 TEMOVATE, 28 TENEX, 15 TENORETIC, 15 TENORMIN, 14 Terazosin, 15 Terbinafine, 19, 27 Terbutaline Sulfate, 22 Teriparatide, 25 TERPIN HYDRATE/CODEINE, 21 Terpin Hydrate/Codeine, 21 TESSALON, 21 Tetracycline, 19 Tetracycline/Bismuth/Metronidazole, 20 Tetracyclines, 19 THEO-DUR, 22 Theophylline, 22 Theophylline, 80mg/15cc, 22 Theophylline, Sustained Release, 22 Thiamine, 30 Thiazide and Related Diuretics, 15 Thioridazine, 13 Thiothixene, 13 THORAZINE, 13 Thyroid Agents, 24 Thyroid, Desiccated, 25
THYROLAR, 24 Tiagabine, 11 TIGAN, 17 TIMOPTIC, 23 TINACTIN, 27 Tioconazole, 27 Tobramycin, 22 TOBREX, 22 TOFRANIL, 12 Tolazamide, 24 Tolbutamide, 24 TOLINASE, 24 Tolnaftate, 27 Tolterodine, 26 TOPAMAX, 12 Topical Antibiotic Agents, 27 Topical Antifungal Agents, 27 Topical Anti-Inflammatory Agents, 28 Topical Antipruritic and Local Anesthetic Agents, 28 Topical Antiviral Agents, 28 Topical Miscellaneous Anti-Infective Agents, 28 TOPICAL/MUCOUS MEMBRANE AGENTS, 27 TOPICORT, 28 TOPICORT LP, 28 Topiramate, 12 TOPROL XL, 14 Tramadol, 11 TRANDATE, 14 TRANXENE, 13 Tranylcypromine, 12 Trazodone, 13 TRENTAL, 16 Triamcinolone, 28 Triamcinolone 0.1% in Orabase, 23 Triamcinolone, Nasal, 23 Triamcinolone/Nystatin, 27 Triamterene, 15 Triamterene 37.5mg/HCTZ 25mg, 15 Triamterene 50mg/HCTZ 25mg, 15 Triamterene 75mg/HCTZ 50mg, 15 Triazolam, 13 Tricyclic Antidepressant Agents, 12 TRIDESILON, 28 Triethanolamine, 24 Trifluoperazine, 13 Trifluridine Ophthalmic Solution, 22 Trihexyphenidyl, 12 TRILAFON, 13 TRILEPTAL, 11 Trimethobenzamide, 17 Trimethoprim, 19, 26 TRIMOX, 19 TRIMPEX, 19, 26 Triple Sulfa Cream, 27 Triprolidine/Pseudoephedrine/Codeine, 21 Tropicamide, 23 TRUSOPT, 23 T-STAT, 27 TUMS, 29
44
TUSSIN PEDIATRIC, 21 TYLENOL, 11 TYLENOL/CODEINE, 11 TYLOX, 11
—U—
ULTRAM, 11 UNIPHYL, 22 URECHOLINE, 26 Urinary Anti-Infective Agents, 26 Urinary Anti-Spasmodic Agents, 26 URISED, 26 Ursodiol, 18
—V—
Vaginal Antifungal Agents, 27 Vaginal Anti-Infective Agents, 28 VAGISTAT-1, 27 Valacyclovir, 20 VALISONE, 28 VALISONE REDUCED STRENGTH, 28 VALIUM, 13 Valproic Acid, 11 Valsartan, 14 Valsartan/HCTZ, 15 VALTREX, 20 Vasodilating Agents, 16 Vasodilator Antihypertensive Agents, 15 VASORETIC, 15 VASOTEC, 14 Venlafaxine, 12 Venlafaxine Extended Release, 12 Verapamil, 15 Verapamil LA Tablets, 15 Verapamil SR Capsules, 15 VERELAN, 15 VERMOX, 18 VIBRAMYCIN, 19 VIBRA-TABS, 19 VIROPTIC, 22 VISCOUS XYLOCAINE, 23 VISKEN, 14 VISTARIL, 14, 21 Vitamin Agents, 30 VITAMIN B1, 30 VITAMIN B12, 30 VITAMIN B6, 30 Vitamin B-Complex Agents, 30 Vitamin D, 30 Vitamin K Activity Agents, 30 VIVACTIL, 12 VIVELLE, 25
VIVELLE DOT, 25 VOLMAX, 21 VOLTAREN, 10, 22 VOSOL, 23 VOSOL HC, 23
—W—
Warfarin Sodium, 16 WELLBUTRIN, 13 WELLBUTRIN SR, 13 WELLBUTRIN XL, 13 WESTCORT, 28
—X—
XALATAN, 23 XANAX, 13 XYLOCAINE, 23, 28
—Y—
YODOXIN, 18, 20
—Z—
ZADITOR OTC, 23 Zanamivir, 20 ZANTAC (TABLETS ONLY), 18 ZAROXOLYN, 15 ZEPHREX LA, 22 ZESTORETIC, 15 ZESTRIL, 14 ZIAC, 15 Ziprasidone, 13 ZITHROMAX, 19 ZOCOR, 16 ZOFRAN, 17 Zolmitriptan, 10 ZOLOFT, 12 Zolpidem, 14 ZOMIG, 10 ZOMIG ZMT, 10 ZONEGRAN, 11 Zonisamide, 11 ZOVIRAX OINTMENT, 28 ZOVIRAX ORAL, 20 ZYBAN, 30 ZYLOPRIM, 30 ZYPREXA, 13 ZYPREXA INJECTION, 13 ZYPREXA RELPREVV, 13 ZYPREXA ZYDIS, 13